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Mrs.    Henry  S.    Cradle 


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DISEASES 


OF  THE 


NOSE,  PHARYNX, 


AND 


EAR 


BY 

HENRYGRADLE,  M.D, 

Professor  of  Ophthalmology  and  Otology  in  the  Northwestern 
University  Medical  School,  Chicago 


ILLUSTRATED 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  &  COMPANY 

1902 


Copyright,  1902,  by  W.  B.  SAUNDERS  &   COMPANY. 


Registered  at  Stationers'  Hall,  London,  England. 


ELEOTROTVPEO  BY 
WESTCOTT  &  THOMSON,    PHILAOA. 


PRESS  OF 
W.   B.   SAUNDERS  II  company. 


PREFACE. 


This  volume  is  intended  to  present  disease  as  the 
author  has  seen  it  during  an  experience  of  nearly  twenty- 
five  years,  while  in  touch  with  the  work  of  others.  It 
has  been  the  author's  aim  to  answer  in  detail  those  ques- 
tions regarding  the  course  and  outcome  of  diseases  which 
cause  the  less  experienced  observer  the  most  anxiety  in 
an  individual  case — questions  to  which  an  answer  is  not 
easily  obtained  from  text-books.  In  order  to  carry  out 
this  plan,  the  book  could  not  be  written  with  the  brevity 
and  sharp  subdivision  of  topics  which  have  made  some 
of  the  smaller  works  popular  with  students.  A  text- 
book should  present  to  the  student  all  the  facts  bearing 
on  the  subject,  and  present  them  in  their  logical  develop- 
ment. But,  on  the  other  hand,  the  work  is  not  intended 
as  an  encyclopedic  treatise,  and  hence  lacks  the  literary 
and  historical  completeness  proper  to  the  latter.  In  the 
therapeutic  part  the  author  has  aimed  to  detail  only  those 
procedures  which  have  stood  the  test  of  critical  experi- 
ence, and  to  omit  those  that  have  failed  under  this  test, 
even  though  sanctioned  by  the  tradition  of  text-books. 

As  a  requisite  for  all  surgical  work,  topographic  anat- 
omy has  been  given  a  liberal  space.  Since  anatomic 
statements  are  necessarily  based  upon  the  labor  of  pro- 
fessional anatomists,  it  has  seemed  proper  to  the  author 
to  draw,  as  well,  upon  the  superior  illustrations  in  some 
of  the  anatomic  works  less  accessible  to  the  English 
student.  It  is  especially  to  the  works  of  Zuckerkandl 
and  of  Politzer  to  which  he  is  indebted  for  anatomic 
illustrations.  * 

9 


CONTENTS. 


BOOK   I. 

DISEASES  OF  THE  NASAL  PASSAGES  AND 
PHARYNX, 


CHAPTER   I. 

PAGE 

Development,  General    Descriptive    Anatomy,    and    Physiology   of    the 

Upper  Air- Passages 17 

CHAPTER   II. 

General  Etiology  and  Hygiene  of  Nasal  and  Pharyngeal  Diseases    ...      40 

CHAPTER   III. 

Symptomatology;  Methods  of  Examination  and  Appearances  of  Nose  and 

Pharynx ;  Methods  of  Treatment  in  Nasal  and  Pharyngeal  Affections  .      51 

CHAPTER    IV. 
Diseases  of  the  Vestibule  of  the  Nose  ;  Coryza 85 

CHAPTER   V. 
Chronic    Nasal    Inflammations;  "Chronic    Catarrh";    Chronic  Purulent 

Rhinitis 92 

CHAPTER   VI. 
Diseases  of  the  Nasal  Accessory  Cavities lOO 

CHAPTER   VII. 
Diseases  of  the  Maxillary  Sinus      125 

CHAPTER   VIII.    • 
Diseases  of  the  Frontal  Sinus,  Ethmoid  Cells,  and  Sphenoid  Sinus    .    .    .     137 

CHAPTER   IX. 

Ozena  (Fetid  Atrophic  Rhinitis) ;  Simple  Atrophic  Rhinitis 155 

11 


1 2  CONTENTS. 

CHAPTER   X. 

PAGE 

Anterior  Dry  Rhinitis;  Perforating  Ulcer  of  the  Septum;  Hematoma  and 

Abscess  of  the  Septum ;  Membranous  and  Diphtheritic  Rhinitis    .    .     163 

CHAPTER   XI. 
Enlargement  of  the  Cavernous  Tissue  (Irritable  Nose — Coryza  Vasomo- 
toria)   168 

CHAPTER   XII. 
Retronasal  Catarrh 174 

CHAPTER   XIII. 
Simple  Chronic  Rhinitis;  Hypertrophic  Rhinitis 177 

CHAPTER   XIV. 
Nasal  Polypi ;  Papillomatous  Tumors 187 

CHAPTER   XV. 

Nasal  Stenosis ;  Collapse  of  the  Sides  of  the  Nose ;  Synechiae ;  Occlusion 

of  the  Posterior  Choanse 194 

CHAPTER   XVI. 
Anatomy  of  the  Septum ;  Deviation  or  Deflection  of  the  .Septum ;  Lateral 

Crests;  Deformity  of  Septum  by  Fracture 200 

CHAPTER   XVII. 
Epistaxis ;  Hydrorrhoea  Nasalis 220 

CHAPTER   XVIII. 
Anatomy  of  the  Tonsils ;  Acute  Inflammation  of  the  Pharynx  and  of  the 

Tonsils  (Angina) 224 

CHAPTER   XIX. 
Peritonsillar  Abscess  or  Quinsy;   Retropharyngeal  Abscess ,    234 

CHAPTER   XX. 
Chronic  Pharyngitis ;  Chronic  Tonsillitis  (Pharyngomycosis  ;  Suppurative 

Pharyngitis) 238 

CHAPTER   XXI. 

Hypertrophy  of  the  Pharyngeal  Tonsil,  or  Adenoid  Vegetations     ....     249 


CONTENTS.  1 3 

CHAPTER    XXII. 

PAGE 

Hypertrophy  of  the  Faucial  Tonsils 264 

CHAPTER   XXIII. 
Hay-fever — Autumnal  Catarrh 272 

CHAPTER   XXIV. 
Diphtheria 279 

CHAPTER   XXV. 
Syphilis  of  the  Nose  and  Pharynx;  Tuberculosis;  Scrofula;   Leprosy; 

Rhinoscleroma 293 

CHAPTER   XXVI. 
Affections  of  the  Upper  Air-Passages  in  the  Course  of  other  Diseases   .    .     308 

CHAPTER    XXVII. 
Tumors  of  the  Nose  and  Pharynx 313 

CHAPTER   XXVIII. 
Foreign   Bodies  in  the  Upper  Air-Passages ;  Rhinoliths  ;  Animal  Para- 
sites ;  Surgical   Injuries  and    Fractures ;  Cicatricial   Contractions  in 
the  Pharynx 322 

CHAPTER   XXIX. 
Influence  of  Nasal  and  Pharyngeal  Affections  upon  Other  Parts  of  the 

Organism    .    .    .    .• 328 


BOOK    II. 
DISEASES  OF  THE  EAR. 


CHAPTER   XXX. 

PAGE 

Anatomy  and  Physiology  of  the  Ear  .    .    .  ^ 345 

CHAPTER   XXXI. 
General  Etiology  of  Ear  Disease 3^^ 

CHAPTER   XXXII. 
Subjective  Symptoms  and  Methods  of  Examination  and  Treatment  in  Ear 

Diseases      .    .    .    v 394 


14  CONTENTS. 

CHAPTER   XXXIII. 

PAGE 

Diseases  of  the  External  Ear  (Othematdma ;  rerichondritis;  Eczema; 
Diffuse  Otitis  Externa;  Furuncles;  Parasitic  Inflammation  of  the 
Meatus;  Wax  and  Epidermis  Plugs) 415 

CHAPTER   XXXIV. 

Diseases  of  the  External  Ear  (Foreign  Bodies ;  Operative  Detachment 
of  the  Auricle  ;  Tumors ;  Stenosis  of  the  Meatus ;  Injuries  ;  Myrin- 
gitis)     423 

CHAPTER   XXXV. 
Diseases  of  the   Middle  Ear   (Catarrh  of  the  Eustachian  Tube;  Serous 

Catarrh  of  the  Middle  Ear;  Syphilitic  Catarrh  of  the  Middle  Ear)   .    429 

CHAPTER   XXXVI. 

Adhesive  or  Proliferative  Inflammation  of  the  Middle  Ear 442 

CHAPTER   XXXVII. 
Operations  for  the  Relief  of  Deafness  due  to  Adhesive  Processes  in  the 

Middle  Ear 453 

CHAPTER   XXXVIII. 
"Sclerosis  of  the  Middle  Ear"  (Rarefaction  of  the  Capsule  of  the  Laby- 
rinth) ;  Ankylosis  of  the  Stapes 457 

CHAPTER    XXXIX. 

^mple  Otitis  Media  (Purulent  Otitis  Media  without  Perforation)    ....    461 

CHAPTER   XL. 
Acute  Purulent  Otitis  Media  (with  Perforation  of  Drumhead) 465 

CHAPTER   XLI. 
Mastoiditis 476 

CHAPTER   XLII. 
Chronic  Purulent  Otitis  Media 488 

CHAPTER   XLIII. 
Local   Complications  of  Chronic    Purulent    Otitis    (Polypi;    Caries   and 
Necrosis    of  the    Bone ;    Cholesteatoma ;    Paralysis   of  the    Facial 
Nerve ;    Tubercular  Otitis) 505 

CHAPTER   XLIV. 
Otalgia 512 


CONTENTS.  1 5 

CHAPTER   XLV. 

PAGE 

Pyogenic  Extension  of  Otitis  (Serous  and  Purulent  Meningitis  ;  Phlebitis 
and  Thrombosis  of  the  Lateral  Sinus  with  Septicemia  or  Pyemia ; 
Subdural  Abscess;  Abscess  of  the  Brain) 514 

CHAPTER   XLVI. 
Diseases  of  the  Internal  Ear 526 

CHAPTER   XLVn. 
Diseases   of  the    Auditory   Nerve    (Anatomy  of  the    Auditory   Nerve) ; 

Deaf-Mutism 535 

INDEX 541 


BOOK  I. 
DISEASES 

OF  THE 

NASAL  PASSAGES  AND  PHARYNX. 


CHAPTER  I 


DEVELOPMENT,  GENERAL  DESCRIPTIVE  ANATOMY, 
AND  PHYSIOLOGY  OF  THE  UPPER  AIR-PASSAGES. 

I.  Development  of  the  Upper  Air-passages. — The 

upper  air-passages  from  nostril  to  larynx  are  developed 
from  three  different  starting-points  during  embryonic 
formation.  The  nasal  or  olfactory  fossae  begin  in  the  form 
of  two  pits  between  and  at  the  level  of  the  embryonic 
eyes.  They  are  separated  from  each  other  by  the  rela- 
tively very  thick  median  frontal  process,  the  lower  curved 
end  of  which  becomes  transformed  into  the  upper  lip. 
Underneath  this  area  the  broad  fissure  constituting  the 
primitive  mouth  reaches  at  first  inward  only  as  far  as 
the  closed  anterior  or  ventral  wall  of  the  esophageal  end 
of  the  intestinal  tract.  The  intestinal  tube  itself  extends 
in  the  form  of  a  blind  pouch  up  to  the  rear  end  of  the 
base  of  the  skull.  The  subsequent  coalescence  of  mouth 
and  esophageal  pouch  forms  the  pharynx.  Meanwhile 
the  nasal  fossae  continue  to  grow  inward  and  to  elongate 
downward.  At  this  period  they  are  but  shallow  longi- 
tudinal fissures,  opening  merely  in  front.  The  external 
nose  covering  the  facial  end  of  the  nasal  passages  is  a 
product  of  a  much  later  stage  of  fetal  development. 
The  floor  that  separates  the  nasal  fossae  from  the  mouth 
— the  primeval  palate — is  the  matrix  of  the  intermaxillary 

2  17 


l8  THE    UPPER    AIR-PASSAGES. 

bone,  and  has  nothing  to  do  with  the  subsequent  true 
palate. 

In  the  next  place  the  nasal  pits  perforate  into  the  mouth. 
For  a  time  the  nasal  passages,  separated  from  each  other  by 
the  thick  septum,  form  one  continuous  space  with  mouth 
and  pharynx.  A  relatively  rapid  growth  of  the  nasal 
fissures  takes  place  in  the  direction  from  the  facial  orifice 
to  the  pharynx,  while  the  median  wall  between  the  nasal 
fissures  is  being  prolonged  by  a  downward  growth  of  a 
partition  from  the  base  of  the  skull  as  well  as  by  the 
elongation  of  the  primitive  septum.  The  final  nasal 
septum  is  thus  formed  from  an  anterior,  as  well  as  from 
an  upper  rear  starting-point.  This  double  development 
is  indicated  during  subsequent  life  by  separate  arterial 
and  nervous  supply  of  the  front  and  posterior  areas  of  the 
median  nasal  wall. 

From  the  matrix  of  the  superior  maxillary  and  palatal 
bones  transverse  plates  begin  to  grow,  which,  by  joining 
finally  in  the  median  line,  form  the  palate  and  thus  sep- 
arate the  nasal  passages  from  the  mouth.  An  arrest  of 
development  of  these  plates  constitutes  the  deformity 
known  as  cleft  palate.  The  orifices  which  remain  at 
the  rear  end  of  the  nasal  fissures  after  the  completion 
of  the  palate  form  the  posterior  choanae, 

2.  By  the  time  the  palatal  plates  have  united  with  each 
other  and  with  the  buccal  edge  of  the  nasal  septum  each 
nasal  passage  has  become  surrounded  with  a  cartilaginous 
capsule,  of  which  the  portion  common  to  both  sides  is 
formed  by  the  cartilaginous  plate  in  the  septum.  On  the 
■external  wall  of  each  nasal  passage  a  series  of  ridges, 
usually  six  in  number,  but  with  accessory  extensions, 
now  develop  in  the  lining,  which  is  transformed  grad- 
ually into  mucous  membrane.  The  ridges,  curved  with 
the  convexity  downward,  converge  from  the  front  and 
the  roof  of  the  nose  toward  the  posterior  choanae.  As 
these  ridges  change  into  projecting  crests,  cartilaginous 
lamellae,  more  or  less  curved,  develop  in  them  and  form 
the  turbinal  processes,  or  conchae.     In  man  but  two  of 


DEVELOPMENT    OF   THE    UPPER    AIR-PASSAGES.  1 9 

these  projecting  lamellae  retain  a  pronounced  prominence 
— the  inferior  and  the  middle  turbinal.  The  others — 
viz.,  the  two  below  the  middle  turbinal  (the  ethmoid 
bulla  and  the  uncinate  process),  as  well  as  all  above  the 
middle  turbinal  (the  ethmoturbinals) — recede  relatively 
in  development,  become  more  or  less  curved  upon  them- 
selves, and  coalesce  to  some  extent.  The  space  between 
the  septum  and  the  turbinal  processes  represents,  finally, 
the  olfactory  fissure  and  the  nasal  passage  proper,  whereas 
the  spaces  included  between  the  coalesced  turbinal  pro- 
cesses develop  into  the  accessory  cavities  or  nasal  sinuses. 
The  formation  of  the  ethmoid  cells  is  thus  a  relatively 
simple  inclusion,  while  the  frontal  and  maxillary  si- 
nuses grow  by  further  extension  into  the  corresponding 
bones.  The  sphenoid  sinus,  however,  represents  really 
the  posterior  (upper)  portion  of  the  nasal  passage  itself, 
shut  off"  by  accessory  turbinal  partitions.  It  is  only  after 
birth  that  these  temporary  walls  around  the  sphenoid 
sinus  atrophy  and  leave  the  cavity  surrounded  by  its  per- 
manent bony  capsule,  formed  by  the  body  of  the  sphenoid 
bone. 

3.  The  infantile  nasal  passage  differs  from  the  fully  de- 
veloped cavity  not  alone  in  its  absolute,  but  also  in  its 
relative,  dimensions.  The  olfactory  area,  or,  more  prop- 
erly defined,  the  region  bounded  by  the  ethmoid  bone,  is 
developed  during  fetal  life  more  fully  than  the  lower  or 
respiratory  channel  outlined  by  the  maxillary  and  palatal 
bones.  The  subsequent  growth  in  the  vertical  height 
of  the  nose  hence  depends  mostly  on  the^postnatal  elonga- 
tion of  the  superior  maxilla.  The  nasal  passage  of  the  infant 
is  relatively  very  narrow,  although  the  extreme  width  of 
the  fetal  septum  has  become  reduced  at  birth  to  the  pro- 
portion maintained  during  adult  life.  The  inferior  tur- 
binal is,  however,  so  close  to  the  floor  and  relatively  so 
broad  that  the  inferior  nasal  meatus  is  scarcely  apparent 
until  about  the  third  year;  hence  inflammatory  swelling 
during  acute  coryza  is  more  serious  in  babes  than  in  later 
life. 


20  THE    UPPER    AIR-PASSAGES. 

Growth  also  occurs  in  the  sagittal  direction.  Until 
the  sixth  year  the  transverse  plane  of  the  posterior 
choanse  corresponds  to  the  level  of  the  infantile  molar 
tooth  (second  bicuspid  of  the  adult).  In  the  course  of  the 
second  dentition  the  palate,  and  with  it  the  nasal  walls, 
elongate  so  that  finally  the  choanae  lie  in  a  plane  with 
the  third  molar  teeth.  The  accessory  sinuses  are  all 
relatively  very  small  and  imperfectly  developed  at  birth. 
Their  growth  is  slow  until  after  the  second  dentition. 

The  pliarynx  at  birth  is  about  one-half  the  size  of  the 
adult  cavity,  except  in  its  width,  it  being  rather  more 
than  one-half  as  wide.  The  growth  of  the  maxilla  and 
the  vertical  plate  of  the  palatal  bones  causes  a  gradual 
displacement  of  the  pharyngeal  orifices  of  the  Eustachian 
tubes  relative  to  the  floor  of  the  nose.  These  orifices, 
situated  below  the  palate  in  the  fetus,  reach  the  level  of 
the  palate  at  birth  and  ascend,  until  the  eighth  year,  to 
the  height  of  the  rear  end  of  the  inferior  turbinal. 

4.  General  Descriptive  Anatomy. — The  Nasal  Cav- 
ity.— The  gateway  to  the  nasal  cavity  is  the  pyriform 
aperture,  bounded  above  by  the  nasal  bones,  on  the 
sides  and  below  by  the  edge  of  the  superior  maxillary 
bones.  The  intermaxillary  portion  of  the  latter  forms 
a  sharp-pointed  median  crest — the  anterior  nasal  spine. 
The  bridge  of  the  nose  is  built  up  by  the  nasal  process  of 
the  frontal  bone,  the  frontal  process  of  the  superior  max- 
illa, and  the  two  nasal  bones  joined  in  the  median  line, 
while  on  the  internal  side  of  this  junction  the  nasal  sep- 
tum is  inserted.  .  The  relative  extent  of  cartilaginous 
portion  of  the  septum  and  bony  portion  (perpendicular 
plate  of  the  ethmoid)  participating  in  this  articulation 
varies  considerably  in  different  subjects.  The  shape  and 
strength  of  the  bridge  of  the  nose  protect  the  septum 
against  traumatic  fracture  from  a  blow  unless  this  be 
sufficiently  intense  to  fracture  the  bridge  itself.  The  shape 
and  prominence  of  the  nasal  bones  are  pronounced  racial 
characteristics.  By  its  protruding  nasal  bridge  the  Cau- 
casian skull  can  be  distinguished  from  that  of  other  races. 


GENERAL    DESCRIPTIVE    ANATOMY. 


21 


Below  the  nasal  bones  the  external  nose  has  a  cartila^i- 
nous  framework  (Fig.  i).  The  septal  or  quadrangular 
cartilage  gives  off  two  approxi- 
mately triangular  wings,  the  tri- 
angular cartilages,  which,  forming 
the  middle  part  of  the  side  of  the 
nose,  adjoin  the  lower  edge  of  the 
nasal  bones,  but  overlap  them  on 
their  internal  side.  Below  this 
level  the  cartilaginous  septum  does 
not  reach  to  the  tip  of  the  nose, 
the  gap  in  the  partition  wall  being 
completed  by  the  movable  mem- 
branous septum.  The  lower  part 
of  the  nasal  side  contains  the  two 
cartilages  of  the  nasal  wing,  each 
a  thin  plate  reaching  from  the  tri- 
angular  cartilage    to   the   tip  and    "^°^i"g  the  skin,  showing 

J         .      .      1  ,      .  ,    •,        the   nasal    bones,    quadran- 

curved  anteriorly  so  as  to  insert  its       ,         ,  .  •       , 

-'  ^  guiar   and   triangular    carti- 

"  doubled"  median  border  into  the    jages  (Zuckerkandi). 

membranous  septum.     In  the  nasal 

wing   this   cartilage    is   fragmented   vertically,    thereby 


Fig.  I. — Front  view  of 
the  external  nose   after  re- 


FlG.  2. — View  of  the  nasal  vestibule  from  below,  showing  the  prominence  of 
the  fold  (Zuckerkandi). 

giving   the   nose   flexibility.      The   triangular   cartilage 
overlaps  the  lower  cartilage  likewise  on  the  internal  side, 


22  THE   UPPER    AIR-PASSAGES. 

and  its  prominent  border  appears  as  a  projecting,  hori- 
zontal fold,  the  plica  vestibuli,  which  may  be  considered 
as  the  threshold  of  the  nasal  cavity,  the  space  outside 
being  the  vestibule  (Fig.  2). 

The  external  skin  lines  the  vestibule  and  changes 
gradually  into  mucous  membrane  at  about  the  level  of 
the  protruding  fold.  As  far  as  there  is  true  skin  the 
vestibule  is  protected  against  insects  by  coarse  hairs — 
the  vibrissae.  The  external  muscles  surrounding  the 
sides  of  the  nose  dilate  the  nostrils,  while  their  relaxa- 
tion results  in  collapse  of  the  sides  of  the  nose,  variable 
with  its  degree  of  flexibility.  The  muscles  are  inner- 
vated by  the  facial  nerve, 

5.  The  nasal  cavities  are  surrounded  entirely  by  bony 
walls,  but  are  separated  from  each  other  by  the  septum, 
which  in  its  front  portion  remains  cartilaginous.  The 
floor  of  the  nose  is  made  up  of  the  palatal  process  of 
the  superior  maxillary  and  the  horizontal  plates  of  the 
palate  bones.  It  is  a  level,  shallow  gutter.  The  floor  is 
the  shortest  of  all  the  nasal  walls,  as  the  rear  edge  of  the 
middle  wall  slopes  backward  and  upward,  besides  being 
slightly  concave  toward  the  rear.  As  the  free  border  of 
the  septum  determines  the  plane  of  the  nasal  opening 
into  the  pharynx,  all  nasal  walls  exceed  the  floor  in 
length. 

The  middle  wall  or  septum  presents  normally  a  nearly 
plane  surface.  The  anatomic  peculiarities  of  this  wall 
will  be  considered  in  Chapter  XVI. 

The  roof,  completed  in  front  by  the  awning  of  the 
nasal  bones,  consists  of  the  cribriform  plate  of  the 
ethmoid  bone  anteriorly,  and  of  the  body  of  the  sphe- 
noid bone  in  its  posterior  half.  The  ethmoid  plate  is  the 
weakest  part.  The  anterior  surface  of  the  sphenoid 
body  slopes  down  and  backward,  while  the  inferior  sur- 
face of  this  bone  has,  likewise,  a  slight  slant  toward  the 
rear  and  down.  The  nasal  space  is  hence  considerably 
lower  in  the  rear  than  in  front  (Fig.   3). 


GENERAL    DESCRIPTIVE    ANATOMY.  2$ 

The  external  wall,  the  most  complicated  of  all,  is 
formed  by  three  bones.  The  greater  area  below  the 
floor  of  the  orbit  consists  of  the  nasal  surface  of  the 
superior  maxilla,  separating  the  nasal  cavity  from  the 
maxillary  sinus.  From  this  there  extends  upward  the 
narrow  frontal  process  of  the  maxillary  bone,  which 
articulates  posteriorly  with  the  lamina  papyracea  of  the 


Fig.   3. — View  of  the  external  wall  of  the  right  nasal  passage,  with  probes  in 
the  sphenoid  sinus  and  in  the  nasal  duct  (Mihalkovics). 

ethmoid  bone,  forming  the  partition  wall  between  the 
orbit  and  the  upper  part  of  nose.  At  its  rear  edge  the 
lamina  papyracea  joins  the  anterior  surface  of  the  sphe- 
noid body,  which,  by  its  presence,  reduces  the  height  of 
the  nasal  passage.  Below  the  sphenoid  bone  and  poste- 
rior to  the  superior  maxilla  the  external  wall  consists  of 
the  vertical  plate  of  the  palate  bone. 


24 


THE    UPPER    AIR-PASSAGES. 


The  space  inclosed  by  the  nasal  walls  is  approximately 
rectangular,  but  is  encroached  upon  in  such  a  manner  by 
accessory  bony  structures,  arising  from  the  external  wall, 
that  each  nasal  cavity  proper  is  reduced  to  a  nearly  tri- 
angular cross-section  with  a  roof  only  2  or  3  mm.  wide, 
while  near  the  floor  each  side  is  from  12  to  18  mm.  wide. 

The  bony  ledges,  which  thus  reduce  the  width  of  the 


Fig.  4. — Frontal  section  through  the  nasal  passages  at  the  level  of  the 
orifice  of  the  maxillary  sinus.  Anterior  half  seen  from  the  rear :  /,  /,  Uncinate 
process  and,  external  to  it,  the  hiatus  semilunaris ;  r,  anterior  half  of  maxillary 
orifice;  d,  infundibulum ;  /,  /,  lamina  papyracea  (Zuckerkandl). 

nasal  passage,  are  the  turbinate  processes  or  turbinals  (or 
conchae).  During  embryonic  formation  there  are  six 
main  turbinal  ledges  or  projecting  lamellae,  with  a  varia- 
ble number  of  minor  shelves  between  them.  They 
follow  a  curve  with  its  convexity  downward  and  forward, 
and  converge  toward  the  posterior  choanae.  By  coales- 
cence and  partial  arrest  of  development  the  number  of 
turbinal  ledges  becomes  reduced,  so  that  at  birth  there 


GENERAL    DESCRIPTIVE    ANATOMY. 


25 


are  but  fonr  or  five.  The  inferior  turbinal  is  a  separate 
bone — a  thin  lamina  in  the  form  of  a  curved,  overhang- 
ing ledge,  a  short  distance  above  the  floor,  which  begins 
within  I  cm.  behind  the  pyriform  aperture  and  ends  in 
the  plane  of  the  posterior  choanse,  where  its  end  is 
slightly  rolled  upon  itself.  It  articulates  with  superior 
maxilla,  palate  bone,  and  lamina  papyracea  of  the  eth- 


FiG.  5. — Frontal  section  through  the  rear  part  of  the  nasal  passages:  A, 
Roof;  B,  floor;  /  external  wall  of  nasal  passages;  C,  C,  alveolar  process,  high 
and  spongy ;  a,  a,  a,  the  three  nasal  meati ;  b,  b,  middle  turbinal ;  c,  olfactory 
fissure;  d,  respiratory  fissure  (Zuckerkandl). 

moid.  The  space  underneath  it  is  the  lower  meatus  ;  the 
channel  above  it,  the  middle  nasal  meatus.  The  other 
turbinal  processes  are  part  of  the  ethmoid  papyraceous 
plate.  Of  these,  the  middle  turbinal  is  the  most  inde- 
pendent. It  conforms,  on  the  whole,  with  the  shape  and 
inclination  of  the  inferior  concha,  begins  about  i  cm. 
posterior  to  the  front  end  of  the  latter,  ending  like  the 


26 


THE    UPPER   AIR-PASSAGES. 


latter  in  the  plane  of  the  posterior  choanse  with  a  similar 
rolled  end.  In  the  living,  no  structure  above  the  middle 
turbinal  can  be  recognized.  Dissection,  however,  shows 
one  well-defined,  though  smaller,  turbinal  process  above 
the  middle  concha,  and  above  this  usually  at  least  one, 
sometimes  two,  smaller  bony  turbinal  folds.  All  these 
structures  are  lined  with  mucous  membrane. 

The  narrow  chink  between  the  nasal  septum  and  the 


Fig.  6. — Frontal  section  through  the  rear  part  of  the  nasal  passages,  show- 
ing the  anterior  surface  of  the  sphenoid.  Through  the  posterior  choanae  a  view 
is  had  of  the  nasopharynx  :  O,  Roof;  a,  anterior  surface  of  the  sphenoid  bone ; 
i>,  b,  depression  between  the  anterior  and  posterior  folds  of  the  upper  nasal  wall ; 
c,  c,  anterior  fold,  d,  posterior  fold,  of  the  upper  nasal  wall ;  e,  spheno-ethmoid 
recess;  ^'orifice  of  sphenoid  sinus;  t,  Eustachian  prominence;  /,/,  pharyngeal 
tonsil  (Zuckerkandl). 

turbinal  surfaces  above  the  middle  turbinal  is  the  olfac- 
tory fissure  in  which  the  nerves  of  smell  spread  out  in 
the  mucous  membrane.  Between  the  middle  and  the 
upper  turbinals  and  the  external  wall  of  the  nasal  cavity 
are  the  ethmoid  cells,  the  spaces  confined  by  the  deviated 
and  partially  coalesced  turbinal  processes  and  accessory 
septa.  These  are  a  series  of  more  or  less  communicating 
cells  lined  by  mucous  membrane  with  orifices  into  the 
nasal  passage  (see  1  43).     Beneath  the  front  end  of  the 


THE    PHARYNX.  2/ 

middle  turbinal  are  the  openings  leading  into  the  frontal 
and  maxillary  sinuses.  The  sphenoid  sinus  communi- 
cates with  the  nasal  space  through  a  slit  in  the  anterior 
sphenoid  wall.  The  only  other  channel  connected  with 
the  nose  is  the  lacrimal  duct,  which  empties  under  the 
external  side  of  the  inferior  turbinal,  close  to  its  front 
end. 

The  nasal  passages  connect  with  the  pharynx  through 
the  posterior  choanse.  These  openings,  each  of  oval 
shape,  are  separated  by  the  posterior  border  of  the  vomer, 
and  are  bounded  above  by  the  lower  surface  of  the  sphe- 
noid ;  externally  and  below,  by  the  palate  bones.  Their 
plane  is  not  quite  vertical,  but  slants  slightly  downward 
and  forward  (Fig.  6). 

6.  The  pharynx  may  be  described  as  a  somewhat  flat- 
tened tube,  increasing  in  width  from  above  downward, 
the  posterior  wall  of  which  curves  over  to  form  the  half- 
dome-shaped  roof.  This  roof  is  level  with  and  contin- 
uous with  the  roof  of  the  nasal  chambers.  The  main 
tunic  of  the  pharynx  is  a  fascia,  the  shape  of  which  is 
best  described  by  its  attachments.  The  periosteum  lining 
the  inferior  surface  of  the  occipital  bone  is  thickened  in 
the  form  of  a  firm  plate,  termed  basilar  fibrocartilage. 
From  this  fibrocartilage,  and  as  a  part  of  it,  the  pharyn- 
geal fascia  extends  downward,  being  fastened  to  the 
slightly  protruding  body  of  the  atlas,  while  below  the 
atlas  it  is  separated  from  the  vertebral  bodies  by  loose 
areolar  tissue.  Laterally,  the  curve  of  the  pharyngeal 
roof  extends  over  to  the  edge  of  the  inferior  surface  of 
the  petrous  pyramids  of  the  temporal  bones,  to  which 
the  fascia  is  fastened,  and  from  which  it  descends.  In 
front  the  fascia  gliding  over  the  short  exposed  (rear)  area 
of  the  lower  sphenoid  surface  adheres  firmly  to  the  bony 
rim  of  the  choanse,  and  thence  passes  transversely  to  the 
inferior  maxilla,  where  it  ends  anteriorly.  The  sides 
and  posterior  wall  of  the  pharynx  are  completely  sur- 
rounded by  the  fascia,  which  thence  continues  down- 
ward as  a  lamella  of  the  cervical  fascia.     The  pharynx 


28  THE   UPPER    AIR-PASSAGES. 

proper  ends  at  the  level  between  the  fifth  and  the 
sixth  cervical  vertebra.  The  pharyngeal  fascia  is  lined 
throughout  with  mucous  membrane,  and  is  surrounded 
below  the  atlas  by  the  constrictor  muscles  of  the  pharynx. 

From  the  foregoing  description  it  is  apparent  that  the 
pharynx  has  no  real  anterior  wall.  Below  its  roof  are  the 
nasal  openings.  Between  the  nasal  passages  and  the 
cavity  of  the  mouth  is  the  bony  palate,  the  plane  of 
which  is  prolonged  by  the  soft  palate.  The  latter  is  a 
muscular  diaphragm  lined  by  nasal  mucous  membrane 
on  its  upper,  and  by  buccal  mucous  membrane  on  its 
under  surface.  The  muscular  fibers  converge  into  the 
palate  from  the  base  of  the  skull,  rim  of  the  choanse, 
and  pharyngeal  walls,  and  end  in  a  tendinous  aponeurosis 
inserted  into  the  rear  border  of  the  bony  palate.  The 
free  posterior  border  of  the  soft  palate  is  concave,  but 
with  a  pendant  tongue-shaped  prolongation  from  its 
center — the  uvula.  Inspection  shows  that  on  each  side 
of  the  uvula  there  arises  a  fold  or  ridge  in  the  mucous 
membrane  of  the  palate,  parallel  with  the  posterior  free 
border,  running  transversely  to  the  insertion  of  the  palate 
at  the  roof  of  the  mouth.  There  the  posterior  palatal 
border  continues  downward  in  the  form  of  another  fold 
of  mucous  membrane  running  down  and  somewhat  back- 
ward,— the  posterior  pillar  of  the  fauces, — while  the 
aforesaid  palatal  ridge  descends  on  the  side  of  the  mouth 
as  the  anterior  pillar  down  to  the  root  of  the  tongue.  By 
the  divergence  of  the  pillars  a  niche  is  formed  for  the 
tonsil.  During  the  act  of  swallowing  and  gagging  the 
faucial  pillars  protrude  in  the  form  of  a  well-defined 
septa  under  the  constricting  influence  of  the  muscles  ex- 
ternal to  the  mucous  membrane.  During  such  move- 
ments the  palate  is  stretched  tense  and  maintained  in  the 
horizontal  plane,  so  as  to  separate  the  nasal  from  the  oral 
part  of  the  pharynx.  When  relaxed,  however,  during 
rest,  the  rear  part  of  the  palate  curves  downward. 

In  the  triangular  niche  between  the  faucial  pillars, 
normally  quite  shallow,  lies  the  tonsil.    The  normal  tonsil 


MEMBRANOUS    LINING    OF    THE    RESPIRATORY    PASSAGE.      29 

is  a  thin  cushion  of  adenoid  tissue  in  the  substance  of  the 
mucous  membrane.  In  our  climate  it  is  more  often  seen 
morbidly  enlarged  than  normal.  Across  the  base  of  the 
tongue  there  stretches  a  bridge  of  adenoid  tissue  from 
one  tonsil  to  the  other — the  lingual  tonsil.  The  (incom- 
plete) ring  of  lymphatic  tissue  in  the  pharynx  surround- 
ing the  buccal  opening  is  completed  by  a  cushion  of 
adenoid  tissue  in  the  mucous  membrane  at  the  roof,  im- 
mediately behind  the  choanae — the  pharyngeal  tonsil. 

The  cartilaginous  portion  of  the  Eustachian  tubes  lies 
underneath  the  lateral  walls  of  the  pharynx,  outside  of 
the  fascia.  As  these  tubes  expand  in  passing  forward, 
downward,  and  slightly  inward,  the  side  of  the  pharynx 
is  made  to  bulge  inward  in  the  form  of  a  flattened  eleva- 
tion. In  front  of  this  tumefaction,  at  the  level  and  back 
of  the  end  of  the  inferior  turbinal,  is  the  Eustachian 
orifice.  By  reason  of  the  divergence  of  the  anterior  and 
posterior  lips  of  the  Eustachian  orifice  the  pharyngeal 
end  of  the  tube  appears  as  an  irregular  triangle  of  a  yel- 
lowish-white color.  The  (variable)  prominence  of  the 
Eustachian  tube  forms  a  recess  at  what  might  be  called 
the  junction  of  the  lateral  wall  of  the  pharynx  with  the 
superoposterior  wall — the  fossa  of  RosenmuUer.  This  re- 
cess becomes  shallower  downward  and  ceases  just  above 
the  level  of  the  palate. 

The  caliber  of  the  pharynx  is,  of  course,  Influenced  by 
movements  of  the  head.  When  the  head  is  inclined 
backward,  the  distance  between  the  palate  and  posterior 
wall  is  lengthened,  whereas  by  depression  of  the  head  it 
is  shortened.  When  the  head  is  turned  to  the  side  by 
rotation  upon  the  axis  (second  vertebra),  torsion  of  the 
pharynx,  which  is  observable  through  the  mouth,  results. 

7.  The  Membranous  Lining  of  the  Respiratory  Passage. 
— The  entire  respiratory  passage  is  lined  by  a  continuous 
mucous  membrane,  which  extends  into  all  communicat- 
ing passages  and  sinuses.  In  the  nose  it  is  thickest  over 
the  inferior  turbinal,  becoming  thinner  in  the  higher  re- 
gions and  still  more  reduced  in  the  pneumatic  cells  and 


30  THE    UPPER    AIR-PASSAGES. 

accessory  sinuses.  Close  examination  shows  a  some- 
what uneven  surface  of  the  nasal  mucous  membrane, 
with  minute  ridges  and  furrows  and  miniature  wart-like 
elevations.  This  unevenness  of  the  surface  is  often 
grossly  exaggerated  in  inflammatory  hypertrophy.  In 
the  pharynx  the  mucous  membrane  is  smoother  but 
thicker ;  it  is  especially  massive,  however,  where  it  is  in- 
filtrated with  adenoid  tissue  so  as  to  form  the  different 
tonsils.  In  the  nose  and  accessory  cavities  the  mucous 
membrane  is  inseparable  from  the  periosteum.  The  tran- 
sition from  skin  to  raucous  membrane  begins  at  about 
the  level  of  the  projecting  fold  in  the  vestibule.  Beyond 
this  threshold,  throughout  the  nose  and  pharynx,  the 
membrane  contains  an  abundance  of  branched  tubular 
mucous  glands;  in  the  nasal  sinuses,  however,  the  glands 
are  few  in  number.  The  surface  epithelium  consists 
of  stratified  cylindric  cells,  of  which  those  on  the  free 
surface  are  ciliated.  Interspersed  are  mucus-forming 
"beaker  cells."  In  the  pharynx,  at  about  the  level 
of  the  second  vertebra,  the  epithelium  changes  into 
stratified  pavement  epithelium.  The  epithelial  cells  in 
the  interior  of  the  mucous  glands  are  cuboid. 

In  the  upper  nasal  region,  which  contains  the  nerves 
of  smell,  the  structure  of  the  lining  membrane,  and  also 
of  its  epithelium,  is  peculiar.  This  area  extends  over  the 
nasal  surfaces  above  the  middle  turbinal  and  anterior  to 
the  sphenoid  sinus,  both  on  the  septum  and  on  the  sur- 
face of  the  upper  turbinal  processes.  Here  the  epithelial 
cells  form  large  cylinders,  not  ciliated  in  the  ordinary' 
sense,  but  presenting  a  few  coarse,  hair-like  "cilia," 
non-motile,  but  presumably  the  specific  end-organs  of  the 
olfactory  nerve. 

Underneath  the  epithelium  there  is  a  well-defined 
structureless  basement  membrane,  with  a  multitude  of 
tubular  perforations,  which  are  probably  the  inlets  (or 
outlets  ?)  of  the  lymphatic  system.  The  substance  of  the 
mucous  membrane  consists  of  a  connective-tissue  stroma 
with  elastic  fibers.     Both  connective-tissue  and  elastic 


MEMBRANOUS    LINING    OF   THE    RESPIRATORY    PASSAGE.      3 1 


Fig.  7. — Histologic  structure  of  the  mucous  membrane  over  the  inferior 
turbinal :  a.  Ciliated  cylindric  epithelium;  b,  basement  membrane;  c,  adenoid 
layer ;  f,  follicle ;  /,  elastic  layer  of  periosteum ;  pc,  cellular  layer  of  periosteum ; 
B,  bone. 

fibers  are  more  or  less  continuous  with  the  periosteum 
over  the  bony  walls,  with  the  perichondrium  over  the 
cartilaginous  part  of  the  septum,  and  with  the  pharyn- 


32  THE    UPPER    AIR-PASSAGES. 

geal  fascia.  Where  the  surface  is  plane  in  the  nose  the 
mucous  membrane  is  easily  detached,  but  wherever  there 
are  bony  crests  or  sharp  angles  it  adheres  firmly  to  the 
underlying  structure,  as  it  does  also  in  the  entire  phar- 
ynx. Along  the  turbinals,  most  noticeably  the  middle 
turbinal,  the  stroma  dips  into  the  smaller  cellular  spaces 
of  the  spongy  bone  and  assumes  a  medullary  structure 
with  the  presence  of  fat-cells.  All  larger  bone-cells,  how- 
ever, are  lined  by  very  thin  mucous  membrane  and 
epithelium. 

Underneath  the  epithelium  the  stroma  presents  a  uni- 
form infiltration  with  lymphoid  cells  throughout  its  en- 
tire extent.  These  round  cells  are  migrator}^,  and  are 
found  penetrating  into  the  epithelial  layer.  This  is  par- 
ticularly the  case  in  the  region  of  the  pharyngeal  tonsil, 
where  the  epithelium  is  crowded  with  lymph-cells.  The 
tonsils  themselves  (pharyngeal,  faucial,  and  lingual)  con- 
sist of  lymphoid  cells  arranged  in  the  form  of  follicles, 
with  incomplete  connective-tissue  capsules  in  the  sub- 
stance of  the  mucous  membrane. 

8.  The  Vascular  Supply  of  the  Upper  Respiratory  Tract. 
— The  whole  lining  of  the  respiratory  tract  is  exceedingly 
vascular.  The  capillaries  are  arranged  in  three  layers — 
a  deep  stratum  close  t6  the  periosteum,  a  coil  of  capil- 
laries aroimd  the  glands,  and  an  extensive  network  in 
the  superficial  adenoid  stratum.  Most  peculiar,  however, 
is  the  arrangement  of  the  veins.  Throughout  the  entire 
mucous  membrane  there  is  a  dense  network  of  veins  with 
small  meshes,  the  caliber  of  the  vessels  increasing  in 
proportion  to  the  distance  of  the  vessels  from  the  surface. 
The  thickness  of  the  mucous  membrane  depends  largely 
on  the  development  of  the  venous  plexus.  In  several 
areas  in  the  nose — viz.,  at  the  anterior  end  of  the  in- 
ferior turbinal,  along  the  margin  of  the  middle  turbinal, 
at  the  rear  ends  of  both  inferior  and  middle  turbinals, 
and  to  a  less  extent  over  the  tuberculum  of  the  septum — 
the  venous  plexus  changes  into  true  cavernous  tissue. 
The  vessels  are  relatively  large,  compared  with  the  inter- 


VASCULAR   SUPPLY   OF   THE    UPPER    RESPIRATORY    TRACT.     33 


Fig.  8. — Cross-section  through  the  mucous  membrane  of  inferior  turbinal 
(posterior  end)  (Hartnack  Obj.  4,  Oc.  2).  The  glandular  vessels  in  exag- 
gerated magnification  :  a,  a,  Subepithelial  layer  with  cortical  vessels  ;  d,  the  lacu- 
nar part  of  the  cavernous  body  with  arteries  verging  toward  the  subepithelial 
layer  (Zuckerkandl). 


MS 


:»£f^rA^f 


Fig.  9. — Cavernous  tissue  of  the  inferior 
turbinal  after  removing  the  superficial  layer 
of  mucous  membrane.  The  interior  of  the 
vessels  is  shaded  (Zuckerkandl). 


Fig.  10. — Cast  of  the  venous 
plexus  over  the  inferior  tur- 
binal :  corrosion  specimen 
(Zuckerkandl). 


34  THE    UPPER    AIR-PASSAGES. 

spaces  between  them;  but,  on  the  other  hand,  they  are 
individually  short,  on  account  of  their  fusion  to  form  a 
network,  and  they  present  an  enormous  development  of 
the  muscular  tunic  not  found  in  ordinary  veins.  When 
not  artificially  injected,  these  veins  show  an  irregular 
puckered  cross-section.  The  density  of  the  venous  net- 
work can  be  observed  best  in  a  corrosion  specimen. 
These  veins  are  fed  only  through  the  capillaries,  and  do 
not  communicate  directly  with  arteries.  The  thickness 
of  the  mucous  membrane  changes  within  wide  limits,  ac- 
cording to  the  degree  of  turgescence  or  collapse  of  the 
cavernous  plexus. 

The  efferent  veins  of  the  nose  are  not  large,  but  they 
are  numerous.  They  emerge  partly  into  the  orbit 
through  the  ethmoid  plate,  into  the  cranial  cavity,  into 
the  palate,  and  to  some  extent  into  the  sides  of  the  phar- 
ynx. Larger  veins  form  a  plexus  around  the  pharynx 
external  to  the  mucous  membrane,  and  empty  into  the 
internal  jugular  vein. 

The  arteries  of  the  nose  and  pharynx  are  likewise  not 
large.  The  sphenopalatine  artery,  a  branch  of  the  in- 
ternal maxillary,  supplies  the  nose  from  the  rear,  emerg- 
ing from  the  sphenopalatine  fossa,  and  sends  branches  to 
both  external  wall  and  septum.  A  collateral  supply  is 
likewise  obtained  from  the  ethmoid  and  external  nasal 
arteries. 

The  pharynx  derives  its  blood  supply  mainly  from  the 
ascending  pharyngeal  artery,  which  ascends  along,  but 
outside  of,  the  lateral  pharyngeal  wall,  enters  at  the  roof, 
and  sends  branches  in  all  directions.  There  is,  besides, 
free  communication  with  all  adjoining  arteries.  The  in- 
ternal carotid  artery  and  internal  jugular  vein  run  par- 
allel to  the  lateral  pharyngeal  wall,  but  are  separated 
from  the  phar^'ngeal  fascia  by  a  layer  of  loose  areolar 
tissue  over  a  centimeter  in  width.  Hence  they  are  not 
endangered  by  ordinary  pharyngeal  operations. 

The  lymph-vessels  form  a  close  network  in  the  sub- 
stance  of  the  mucous  membrane,    and  empty   through 


PHYSIOLOGY    OF    THE    UPPER    RESPIRATORY    PASSAGES.       35 

channels  in  the  soft  palate  and  pharyngeal  walls  into 
the  cervical  lymph-passages  and  glands.  In  animals  a 
communication  has  been  shown  between  the  subarach- 
noid spaces  and  the  nasal  lymph-channels.  In  man  this 
connection  has  not  been  demonstrated.  Injection  of  the 
lymph-vessels  allows  the  fluid  to  escape  through  the 
tubular  perforations  in  the  basement  membrane  into  the 
epithelial  layer,  even  up  to  the  free  surface. 

9.  The  Nerve  Supply  of  the  Upper  Respiratory  Tract 

The  specific  nerve  of  smell  is  the  olfactory  nerve,  which 
sends  its  branches  through  perforations  in  the  lamina 
cribrosa  in  two  rows,  of  which  the  inner  row  descends 
along  the  septum,  whereas  the  outer  spreads  over  the  ex- 
ternal wall  as  far  as  the  attachment  of  the  middle  tur- 
binal.  The  nerves  of  ordinary  sensation  of  the  nose  are 
branches  of  the  fifth  nerve.  The  embryonic  formation 
of  the  septum — and,  to  a  certain  extent,  of  the  nasal 
walls — from  two  distinct  areas  of  development  accounts 
for  the  peculiar  double  supply  of  nerve-fibers.  A  branch 
of  the  first  division  of  the  fifth  nerve — the  ethmoid — 
enters  the  nose  through  the  ethmoid  canal  and  supplies 
the  anterior  area  of  the  septum  and  the  external  wall. 
The  entire  rear  region,  however,  derives  its  fibers — the 
postnasal  nerves — from  the  second  division  of  the  tri- 
geminus. These  fibers,  coming  from  Meckel's  ganglion, 
enter  above  and  posteriorly  from  the  sphenopalatine  fossa. 
The  pharynx  receives  its  sensory  fibers  from  the  pharyn- 
geal plexus,  which  is  made  up  of  branches  from  the 
vagus,  spinal  accessory,  and  glossopharyngeal  nerves. 
This  plexus  supplies  also  motor  nerves  to  the  pharyngeal 
and  palatal  muscles,  except  the  tensor  palati  muscle, 
which  is  innervated  by  the  internal  pterygoid  branch  of 
the  trigeminus.  The  muscles  of  the  external  nose,  which 
dilate  the  nostrils,  are  under  the  control  of  the  facial 
nerve. 

10.  Physiology  of  the  Upper  Respiratory  Passages. 
— The  nasal  passage  fulfils  a  double  purpose.  It  contains 
the  organ  of  smell,  and  it  serves  as  the  main  channel  for 


36  THE    UPPER    AIR-PASSAGES. 

the  entrance  and  exit  of  air  in  breathing.  The  olfactory 
nerve-ends  ramify  over  a  much  smaller  area  in  man  than 
in  most  of  the  lower  animals,  and  the  sense  of  smell  is 
correspondingly  less  highly  developed  and  of  smaller  im- 
portance in  man.  The  olfactory  area  in  the  human 
being  is  limited  to  the  surface  of  the  septum  and  the  ex- 
ternal wall,  above  the  middle  turbinal  and  anterior  to  the 
sphenoid  bone.  The  current  of  air  bearing  odoriferous 
particles  or  vapor  enters  the  narrow  olfactory  chink 
during  ordinary  inspiration,  but  it  is  directed  thither 
more  forcibly  during  sniffling, — short,  abruptly  ending 
inspirations, — which  creates  eddies  in  the  intranasal  air- 
current  and  thus  favors  diffusion.  The  expired  air  does 
not  enter  the  olfactory  fissure  on  account  of  the  configura- 
tion of  the  posterior  choanae.  For  this  reason  odors 
arising  from  the  presence  of  decomposed  secretions  in  the 
throat  and  nose  are  not  perceptible  to  the  patient  himself. 
Inflammatory  swelling  leads  readily  to  occlusion  of  the 
olfactory  chink,  thereby  abolishing  the  sense  of  smell 
temporarily.  To  what  extent  the  nerves  of  smell  and 
their  terminal  epithelia  suffer  permanently  in  various 
nasal  diseases  has  never  been  determined. 

By  reason  of  the  shape  of  the  vestibule,  the  current  of 
air  during  inspiration  is  directed  somewhat  upward,  and 
describes  a  curved  path  mainly  through  the  middle 
meatus  to  the  posterior  choanae.  Eddies  are  produced  in 
the  air-current  on  account  of  the  various  irregularities  of 
the  intranasal  surfaces,  and  this  rotar}'  motion  favors  per- 
meation of  all  recesses  by  the  moving  air.  In  its  passage 
through  the  nose  the  air  undergoes  three  changes:  It  is 
warmed  nearly  to  the  body-temperature,  is  saturated  with 
aqueous  vapor,  and  is  partially  freed  from  dust.  This  in- 
fluence upon  the  inspired  air  is  due  to  the  large  expanse 
of  nasal  surface  and  its  high  degree  of  vascularity.  The 
absolute  amount  of  warmth  imparted  to  the  air  depends, 
of  course,  upon  its  previous  temperature.  The  quantity 
of  moisture  lost  by  the  nose  varies  likewise  with  the 
atmospheric  conditions.     The  saturation  of  the  inspired 


PHYSIOLOGY    OF    THE    UPPER    RESPIRATORY    PASSAGES.       3/ 

relatively  dry  air  of  a  winter's  day  requires  about  30  grams 
of  water  an  hour.  This  high  figure  would  naturally  be 
much  reduced  on  warm  days  or  in  moist  weather.  The 
deposition  of  dust  is  favored,  no  doubt,  by  the  vestibular 
hairs,  but  depends  mostly  on  the  convolutions  of  the 
moist  surface  over  which  it  passes.  This  clearing  of  the 
air  is  not,  however,  absolute,  and  the  filtering  mechanism 
proves  insufficient  when  the  air  is  unusually  dust)'.  The 
deposited  dust  containing  living  germs  is  expelled  from 
the  nose  by  the  pushing  motion  of  the  epithelial  cilia, 
which  wave  in  the  direction  toward  the  anterior  nares. 
Experimentation  has  shown  that  in  spite  of  the  micro- 
scopic dimensions,  the  energy  of  the  ciliary  motion  is 
quite  considerable,  on  account  of  the  rapidity  of  the 
vibrations.  Various  observers  have  found  that  the  inter- 
nasal  surfaces  harbor  remarkably  few  bacteria,  although 
every  breath  of  air  deposits  its  living  dust.  It  has  been 
claimed,  but  has  not  been  definitely  proved,  that  the 
nasal  mucus  possesses  some  bactericidal  properties.  The 
surface,  to  the  depth  of  the  cilia  on  the  epithelial  cells, 
is  continuously  bathed  by  a  layer  of  mucus,  but  during 
health  there  is  never  sufficient  secretion  to  flow  along  or 
accumulate  on  the  surface  except  momentarily  in  re- 
sponse to  irritation.  This  statement  applies  equally  to 
the  pharyngeal  lining. 

Narrowness  of  one  side  of  the  nose  does  not  interfere 
with  ordinary  breathing  if  compensated  for  by  sufficient 
width  of  the  other  side.  It  makes  the  subject,  how- 
ever, short-winded  on  exertion.  But  if  both  nasal  pas- 
sages are  insufficient,  a  reflex  mechanism  enforces  open- 
ing of  the  mouth  and  mouth-breathing  results.  In  its 
passage  through  the  mouth  the  air  is  not  warmed, 
moistened,  nor  clarified  to  the  same  extent  as  occurs  in 
nasal  breathing.  Although  it  cannot  be  said  that  cool, 
relatively  dry  or  dusty  air  is  directly  a  cause  of  disease  of 
the  lower  air-passages,  it  undoubtedly  exercises  an  un- 
favorable effect  that  may  aid  other  disease-producing 
influences.     In    nurslings    the    mechanism    of    mouth- 


38  THE    UPPER    AIR-PASSAGES. 

breathing  is  not  yet  fully  established,  and  hence  nasal 
obstruction  is  more  distressing  to  them,  especially  during 
nursing. 

The  soft  palate  act^  as  a  triple  valve  between  nose, 
pharynx,  and  mouth.  When  its  muscles  are  at  rest  there 
is  free  communication  between  these  three  spaces. 
During  the  act  of  swallowing — likewise  gagging  and 
retching — the  nasal  part  of  the  pharynx  is  shut  off  from 
the  lower  region.  The  palate  is  stretched  horizontally 
and  is  tense,  the  posterior  pillars  are  changed  into  pro- 
jecting septa  applied  against  the  posterior  wall,  while 
the  constrictor  muscles  of  the  pharynx  narrow  its  caliber 
and  cause  its  posterior  wall  to  touch  the  edge  of  the 
palate.  When  this  mechanism  is  viewed  from  above 
through  the  nasal  passage,  widened  by  any  destructive 
disease,  the  pharyngeal  wall  appears  constricted  in  a 
ridge  meeting  the  elevated  palate.  This  protrusion,  due 
to  the  action  of  the  constrictor  muscles,  is  known  as 
Passavant's  ridge.  Incidentally  the  levator  and  tensor 
palati  muscles  cause  the  Eustachian  orifice  to  gape 
during  their  contraction  in  swallowing.  When  the 
palatal  muscles  are  paralyzed,  as  in  postdiphtheritic  pa- 
ralysis, the  closure  of  the  nasopharynx  is  incomplete  and 
food  and  fluids  find  their  way  into  the  nose.  If  nasal 
breathing  is  to  continue  while  the  mouth  is  open,  the  air 
is  kept  out  of  the  mouth  by  elevation  of  the  base  of  the 
tongue,  while  slight  tension  of  the  muscular  fibers  in  the 
anterior  faucial  pillars  pulls  the  pendant  palate  against 
the  tongue. 

During  speech  the  palate  is  in  a  variable  state  of 
activity.  Pure  vowels  are  produced  only  when  the  air 
passes  through  the  mouth  and  the  palate  is  partially 
raised.  If  a  part  of  the  air  passes  into  the  nose,  the 
vowel  has  a  nasal  twang.  The  most  pronounced  nasal 
sound,  "ng,"  occurs  during  absolute  relaxation  of 
the  palate.  The  position  of  the  palate  varies  with  the 
different  consonants.  A  very  sensitive  test  to  detect  the 
passage   of  air   through    the    nose    during  intonation  is 


PHYSIOLOGY    OF    THE    UPPER    RESPIRATORY    PASSAGES.       39 

furnished  by  a  cold  mirror  held  in  front  of  the  nostril, 
upon  which  the  expired  air  will  deposit  its  moisture. 

II.  The  nasal  membrane  is  very  sensitive  to  touch, 
although  deep  incisions  produce  only  moderate  pain. 
The  nasal  sensitiveness  resists  anesthetics  to  such  an  ex- 
tent that  tickling  of  the  inside  of  the  nose  with  a  feather 
is  sometimes  of  service  in  impending  failure  of  respiration 
during  narcosis.  Nasal  irritation,  mechanical  or  chemical, 
results  in  sneezing  and  the  free  flow  of  a  thin,  mucous 
secretion.  The  surface  of  the  pharynx  is  less  acutely 
sensitive  than  the  nasal  lining,  and  its  mechanical  irrita- 
tion distresses  mainly  by  reason  of  the  reflex  retching 
movements  that  it  calls  forth.  Mucous  secretion  from 
the  pharynx,  brought  on  by  irritation,  is  more  viscid 
than  the  nasal  fluid. 


CHAPTER   II. 

GENERAL   ETIOLOGY   AND    HYGIENE   OF   NASAL 
AND    PHARYNGEAL   DISEASES. 

la.  Origin  of  Nasal  and  Pharyngeal  Diseases. — 

Most  nasal  and  pharyngeal  aflfections  are  of  inflammatory 
origin,  being  due  either  to  an  acute  or  a  chronic  inflam- 
matory lesion  or  to  its  consequences.  Acute  coryza, 
either  simple  or  as  part  of  some  infection  (influenza, 
measles),  and  the  residual  inflammatory  processes  that 
may  persist  afterward,  as  well  as  hypertrophies  thus  pro- 
duced, the  involvement  of  the  accessory  cavities  in  the 
course  of  a  coryza  or  as  part  of  some  general  affection, 
and  the  various  forms  of  inflammation  and  enlargement 
of  the  pharyngeal  lymphatic  tissue  are  responsible  for 
most  of  the  complaints  referred  to  the  nose  and  throat. 
The  parasites  giving  rise  to  these  infections  have  been 
only  partly  identified.  The  microbe  of  common  coryza 
has  as  yet  escaped  detection,  although  the  history  of  the 
disease  leaves  no  reasonable  doubt  that  it  is  of  microbic 
origin,  while  its  frequency  indicates  the  universal  distri- 
bution of  the  virus.  It  has,  likewise,  not  been  fully  es- 
tablished to  what  extent  secondary  infection  with  the 
various  familiar  pathogenic  microbes  is  responsible  for 
the  prolongation  of  a  coryza.  In  affections  of  the  nasal 
sinuses  the  various  forms  of  pyogenic  bacteri'a — staphy- 
lococci, streptococci,  pneumococci,  diphtheria  bacilli,  coli- 
bacilli, and  others — have  been  found.  Tonsillitis  is  due 
mostly  to  streptococci,  occasionally  to  other  forms.  A 
limited  role  is  played  by  specific  infection  in  the  nose 
and  pharynx  by  the  diphtheria  bacillus,  the  bacillus  tu- 
berculosis, and  the  virus  of  syphilis. 

13.  "  Colds." — Of  equal,  if  not  of  greater,  clinical  im- 

40 


"colds."  41 

portance  than  the  identification  of  a  parasite  is  the  recog- 
nition of  the  external  and  internal  conditions  which  favor 
or  even  determine  infection.  Of  all  influences,  that  of 
' '  taking  cold ' '  is  most  often  accused  by  the  layman  to 
be  the  cause  of  nasopharyngeal  disorders.  Indeed,  in 
the  mind  of  the  laity  the  etiologic  aspect  has  been  so  con- 
founded with  the  pathology  that  most  nasal  and  throat 
diseases  are  commonly  called  "cold."  This  universal 
belief  is  supported  only  to  a  very  limited  extent  by  tan- 
gible evidence. 

It  is  a  matter  of  frequent  observation  that  individuals 
who  have  chronic  affections  and  structural  lesions  in  the 
upper  air-passages  experience  at  times  acute  aggravations 
within  from  twelve  to  twenty-four  hours  after  a  chilling 
of  part  or  the  whole  of  the  surface  of  the  body.  In  some 
instances  it  is  prolonged  chilling  of  the  feet;  in  others, 
the  exposure  of  the  head  and  shoulders  to  a  draft,  espe- 
cially when  these  parts  were  previously  warm.  Some- 
times, perhaps  less  often,  it  is  the  cooling  of  the  entire 
skin  which  apparently  leads  to  an  acute  intensification 
or  extension  of  an  existing  inflammatory  process  of  low 
grade.  The  difficulty  of  investigating  these  occurrences 
is  very  much  increased  by  the  fact  that  such  exposure 
is  not  always  followed,  by  the  same  results,  and  that,  on 
the  other  hand,  the  history  of  exposure  does  not  always 
precede  such  exacerbations.  Yet  the  significance  of 
exposures  of  this  kind  is  sometimes  demonstrated  by 
the  success  with  which  patients  evade  these  "colds" 
after  their  attention  has  been  called  to  the  necessity  for 
better  protection.  Strongly  suggestive,  too,  of  the  reality 
of  "  taking  cold"  is  the  common  experience  that  these 
aggravations  are  least  likely  to  occur  under  conditions  of 
equable  weather — for  instance,  in  midsummer.  It  is  not, 
however,  the  constant  cold  of  winter  that  experience  has 
shown  to  exert  the  most  marked  influence,  but,  rather, 
the  sudden  thermometric  changes  in  fall  and  spring, 
especially  when  combined  with  humidity  and  chilling 
winds.     In  this  connection  it  is  of  interest  to  remember 


42  NASAL   AND    PHARYNGEAL    DISEASES. 

that  various  arctic  explorers  (Nordenskjold  and  Nansen) 
have  spoken  of  the  noteworthy  exemption  of  their  crews 
from  "colds"  while  wintering  in  the  far  north. 

All  these  observations  confirm  the  view  that  chilling 
of  the  skin  can  play  an  important  role  in  intensifying 
nasal  and  pharyngeal  inflammations  and  causing  their 
extension — at  least  when  combined  with  other  influences 
the  nature  of  which  is  as  yet  unknown.  Whether,  how- 
ever, the  act  of  "taking  cold"  can  give  rise  to  an  in- 
flammation in  a  nose  or  throat  hitherto  entirely  normal  is 
an  undecided  problem.  In  most  cases  that  belong  to  this 
category  a  history  of  exposure  cannot  be  obtained  with 
the  definiteness  requisite  for  scientific  reasoning.  Yet 
the  seasonable  distribution  of  fresh  attacks  of  coryza  and 
of  tonsillitis  lends  some  color  to  the  view  that  they,  too, 
may  result,  under  some  circumstances,  from  "taking 
colds." 

It  is  probable  that  the  mechanism  of  "  taking  cold  " 
consists,  in  part,  in  circulatory  disturbances.  In  persons 
in  whom  previous  nasal  disease  has  led  to  enlargement 
of  the  cavernous  venous  tissue  the  influence  of  chilling 
of  the  warm  skin  upon  the  intranasal  circulation  can  be 
studied  advantageously.  Under  these  circumstances  ex- 
posure immediately  gives  rise  to  a  turgescence  of  the 
nasal  mucous  membrane,  usually  with  sneezing,  and  fol- 
lowed by  a  watery  discharge  from  the  nose.  As  a  rule, 
these  disturbances  cease  in  a  short  time.  It  probably 
requires  the  conjoint  influence  of  other  unknown  factors, 
together  with  chilling,  in  order  to  start  or  extend  infec- 
tion in  the  nose. 

The  Prevention  of  "  Colds.'''' — In  giving  advice  regard- 
ing protection  against  "taking  cold,"  it  is  necessary  to 
individualize.  Cast-iron  rules  concerning  clothing  are 
neither  supported  by  experience  nor  are  they  likely  to  be 
accepted  by  many  patients.  The  most  sensible  plan  is 
simply  to  wear  comfortable  clothing  suitable  to  the  time 
of  the  year  and  to  be  prepared  for  sudden  changes  in  the 
weather. 


COLDS,  43 

The  amount  of  clothing  requisite  for  this  purpose 
varies  with  the  vigor  and  habits  of  the  individual. 
Most  persons  are  apt  to  be  indifferent  regarding  chill- 
ing of  the  feet;  hence  advice  concerning  woolen  stock- 
ings, heavier  shoes,  overgaiters,  or  rubbers  is  often  fol- 
lowed by  benefit. 

Cold  feet  are  due,  in  some  instances,  to  the  evaporation 
of  a  profuse  perspiration.  This  can  be  controlled  effec- 
tually and  permanently  by  a  single  foot-bath  of  a  few 
minutes'  duration  in  a  5  per  cent,  solution  of  chromic 
acid.  On  account  of  the  possible  poisonous  effect  of 
chromic  acid  upon  the  kidneys  the  writer  has  limited  the 
application  to  one  foot  at  a  time,  and  has  never  had  any 
unpleasant  results.  Formalin  in  full  strength  will  also 
control  excessive  perspiration,  but  must  be  used  re- 
peatedly at  intervals  of  weeks.  When  cold  feet  are  due 
merely  to  a  poor  cutaneous  circulation,  this  can  be 
improved  satisfactorily  by  the  use  of  tincture  of  capsi- 
cum as  a  foot-wash  continued  for  days  or  weeks.  Good 
results  are  also  obtainable  by  daily  foot-baths,  alternating 
a  few  times  between  cold — not  cool — and  hot  water,  and 
finishing  with  the  latter. 

Temperature  of  Diuellings. — As  the  temperature  of  the 
interior  of  houses  is  not  much  lower  in  winter  than  in 
summer,  it  is  wiser  to  adapt  one's  self  for  the  cold  out- 
doors by  wearing  changeable  outer  garments  rather  than 
by  an  excessive  quantity  of  underclothing.  Muffling  of 
the  neck  is  often  found  to  increase  the  liability  to 
"colds." 

So  far  as  it  is  possible,  attempts  should  also  be  made 
to  regulate  the  temperature  of  the  interior  of  dwellings, 
avoiding  both  extremes, — excessive  heat  and  unpleasantly 
low  temperatures, — and  giving  due  regard  to  ventilation. 
An  unbiased  observer  can  hardly  escape  the  conclusion 
that  the  popular  fear  of  drafts  does  more  damage  to  the 
general  health,  by  causing  people  to  live  and  sleep  in 
a  vitiated  atmosphere,  than  an  indifference  to  drafts 
would   do,   even    if  it  be  responsible  for   an    occasional 


44  NASAL   AND    PHARYNGEAL    DISEASES. 

"cold."  Much  of  the  fear  expressed  by  various  writers 
regarding  the  dangers  due  to  the  dryness  of  the  air 
caused  by  artificial  heating,  especially  by  steam,  in 
winter,  is  based  on  speculative  reasoning  only.  Most 
of  the  Western  States,  especially  the  mountain  regions, 
have  a  very  low  relative  humidity,  while  their  climate  is 
universally  acknowledged  to  be  very  "healthful."  The 
compensatory  ability  of  the  organism  is  such  that  it  can 
adapt  itself  to  wide  variations  in  the  surrounding  physi- 
cal conditions. 

There  can  be  little  doubt  that  the  ability  to  resist 
unfavorable  meteorologic  influences  depends  largely  on 
the  individual's  habits  and  training.  Restrictive  anxiety, 
especially  when  it  interferes  with  an  outdoor  life  in  the 
rearing  of  children,  is  probably  more  disastrous  than 
negligence  in  the  other  direction. 

Cold  baths  and  cold  sponging  are  recommended  highly 
by  text-books  as  preventives  against  "colds."  A  fairly 
large  experience,  started  originally  with  some  enthusiasm, 
leads  the  writer  to  believe  that  the  efficiency  of  this 
measure  is  somewhat  overrated  as  regards  its  influence 
upon  the  resisting  power  of  the  respiratory  passages.  Yet 
he  would  heartily  recommend  a  daily  cold  plunge  for  its 
general  tonic  effect,  provided  it  be  followed  by  a  com- 
fortable reaction  and  a  feeling  of  warmth.  In  anemic 
and  neurasthenic  conditions  this  reaction  is  sometimes 
not  obtainable.  It  is  more  likely  to  follow  a  quick  cold 
plunge  than  a  cool  bath  or  the  mere  sponging  of  the 
skin.  Diseases  and  chronic  lesions  of  the  upper  respira- 
tory passages  need  not  interfere  with  baths  of  any  kind. 
Baelz,  with  sixteen  5^ears'  medical  experience  in  Tokio, 
states  that  the  Japanese  take  one  or  more  baths  daily  at 
from  42°  to  44°  C,  many  of  them  passing  at  once  into 
the  streets,  thinly  clad,  even  in  cool  weather.  Experience 
has  not  shown  that  "colds"  result  from  this  practice. 
It  is  also  well  known  that  the  change  from  the  hot  steam 
room  to  the  cold  plunge  in  Russian  baths  is  not  ordinarily 
followed  by  unpleasant  consequences. 


IN'FLUEN'CE    OF    CLIMATE.  45 

14.  The  Influence  of  Climate  on  Diseases  of  the 
Upper  Air-passages. — Regarding  the  influence  of  cli- 
mate upon  affections  of  the  air-passages,  there  is  as  yet 
but  little  precise  knowledge.  The  best  known  instance 
of  the  influence  of  climate  on  disease  is  shown  by  the 
immunity  of  certain  localities  to  hay-fever.  These  are 
partly  mountain  resorts,  partly  the  shores  of  various 
bodies  of  water.  This  disease,  which  is  not  an  inflam- 
matory process,  but  essentially  a  nervous  disturbance,  is 
promptly  arrested  when  the  sufferer  arrives  in  these 
exempt  localities.  Common  to  them  all  is  the  relative 
absence  of  dust.  Many  other  dust-free  localities  do  not, 
however,  grant  similar  immunity.  A  definite  climatic 
influence  can  also  be  observed  with  regard  to  the  nervous 
symptoms  and  disturbances  that  are  often  caused  by 
"perennial"  turgescence  of  cavernous  tissue  in  the 
nose — sneezing  fits,  asthma,  headache,  etc.  They  are 
promptly  relieved  on  reaching  moderate  altitudes  in  the 
mountains,  and,  as  a  rule,  are  permanently  benefited  by 
a  sojourn  in  such  localities.  Apart  from  these  two 
instances,  there  is  much  diversity  of  opinion  regarding 
the  effects  of  climate  upon  the  nose  and  throat.  The 
author's  impressions,  based  upon  the  histories  of  travel- 
ing patients  or  those  who  have  permanently  changed 
their  residence,  and  upon  discussion  with  physicians  in 
different  parts  of  the  country,  as  well  as  upon  some 
personal  traveling  experiences,  may  be  stated  in  this 
manner:  Acute  attacks  and  acute  inflammatory  exacerba- 
tions occur  most  frequently  where  there  are  sudden 
changes  in  temperature,  prolonged  spells  of  wet  and  cold 
weather,  and  irregular  winds.  On  the  other  hand,  they 
are  least  likely  to  occur  where  the  temperature  is  equable, 
especially  when  there  are  no  prolonged  spells  of  high 
atmospheric  humidity,  and  where  the  winds,  even  if 
intense,  occur  with  a  certain  regularity.  All  these  hy- 
gienic conditions  exist  more  on  the  western  than  on  the 
eastern  side  of  the  Rocky  Mountains,  and  especially  in 
the  Southwestern  States.     Since  all  chronic  lesions  in 


46  NASAL    AND    PHARYNGEAL    DISEASES. 

the  nose  and  pharynx  are,  as  a  rule,  aggravated  by  acute 
exacerbations,  a  residence  in  the  Western  States,  and 
especially  in  the  southwestern  parts  (California,  Arizona, 
New  Mexico,  Southern  Utah),  is  less  likely  to  intensify 
or  maintain  nasal  disturbances  than  living  in  the  Middle 
or  Eastern  States.  Moreover,  as  irritative  symptoms 
(sneezing,  asthma,  etc.)  are  usually  promptly  relieved  by 
the.  western  climate,  especially  at  moderate  altitudes, 
excepting  in  dusty  regions,  patients  often  experience 
much  benefit  from  a  trip  to  these  parts  of  the  country. 
Regarding  its  influence  upon  inflamed  nasal  passages, 
Colorado  is  not  praised  by  its  own  physicians,  but,  in 
the  author's  experience,  his  patients  have  usually  been 
benefited  bv  its  drvness  and  sunshine.  Regarding  the 
Southern  States  east  of  the  Rocky  Mountains  his  own 
impressions  have  been  much  less  favorable.  There 
are,  however,  many  chronic  conditions,  such  as  deep- 
seated  suppurative  foci  and  hypertrophic  lesions,  that 
will  not  disappear  under  climatic  influences  alone, 
although  the  subjective  annoyance  produced  by  them  is 
reduced  by  favorable  climatic  environment. 

15.  Factors  in  the  Etiology  of  Diseases  of  the 
Upper  Respiratory  Organs. — Of  great  etiologic  impor- 
tance in  the  pathology  of  the  upper  air-passages  are  the 
anatomic  configuration  and  the  changes  resulting  from  previous 
disease.  It  can  be  readily  observed  clinically  that  both 
suppurative  and  hypertrophic  processes  occur  predomi- 
nantly in  narrow  nasal  passages,  narrow  either  froui  pro- 
nounced relative  narrowness  of  the  skull  or  encroachment 
of  the  external  nasal  wall  upon  the  caliber.  Wide  pass- 
ages, on  the  other  hand,  appear  in  the  minority  in  nasal 
affections,  except  in  ozena,  to  which  they  predispose. 
Even  more  important  are  circumscribed  encroachments 
upon  the  caliber  of  the  passages,  such  as  deflections  of  the 
septum,  crests  upon  the  .septum,  hypertrophies  of  mucous 
membrane,  and  enlargement  of  the  pharyngeal  lymphatic 
tissue.  Hypertrophic  processes  accompanied  by  inflam- 
mation thus  tend  to  perpetuation,  by  reason  of  the  vicious 


FACTORS    IN    ETIOLOGY.  47 

circle  to  which  they  give  rise.  In  one-sided  nasal  steno- 
sis it  is  especially  noticeable  that  any  acute  and  ordinarily 
transient  inflammation  is  likely  to  become  persistent  on 
the  narrower  side  of  the  nose,  or  to  extend  to  the  ear  of 
that  side.  Striking,  too,  is  the  diminished  liability  to 
acute  "colds"  after  a  properly  indicated  removal  of  a 
pharyngeal  tonsil,  a  successful  septum  operation,  or  cau- 
terization of  redundant  tissue.  There  are,  moreover,  some 
inflammatory  processes,  which,  even  though  they  seem 
to  have  healed  entirely,  as  judged  by  clinical  evidence, 
create  a  disposition  to  their  own  recurrence,  such  as  acute 
inflammation  of  the  frontal  sinus,  and  especially  tonsil- 
litis. Hence  the  surgical  treatment  of  existing  chronic 
lesions,  even  when  they  cause  but  little  discomfort,  plays 
an  important  role  in  the  prophylaxis  of  nasopharyngeal 
affections. 

The  liability  to  structural  changes  depends  often  on 
hereditary  peculiarities.  Enlargement  of  the  pharyngeal 
tonsils  is  strikingly  frequent  in  some  families;  in  others, 
it  is  totally  absent. 

i6.  Although  most  of  the  diseases  of  the  nose  and 
pharynx  are  strictly  localized  processes,  their  occurrence 
and  persistence  are  in  some  instances  more  or  less  de- 
pendent upon  morbid  conditions  elsewhere  in  the  body.  A 
specialist  can  never  afford  to  lose  his  interest  in  general 
pathology. 

The  liability  to  "colds"  is  increased  by  anemia  and 
other  conditions  of  malnutrition,  and  diminishes  asfain 
with  returning  systemic  vigor.  Of  acute  infections  of 
the  accessory  sinuses,  the  majority  are  incident  in  the 
course  of  infectious  diseases,  as  shown  by  autopsies.  While 
most  of  the  sinus  involvements  under  these  circumstances 
present  but  few  clinical  symptoms,  yet  a  small  number 
turn  into  chronic  and  persistent  forms.  In  affections  of 
the  maxillary  sinus  the  origin  must  be  sought  in  carious 
teeth  in  a  moderate  proportion  of  cases. 

Inflammatory  processes  in  nose  and  throat  are  also 
largely  influenced  by  disturbances  of  the  digestive  system. 


48  NASAL   AND    PHARYNGEAL    DISEASES. 

The  various  forms -of  dyspepsia,  and  especially  constipa- 
tion, are  often  a  serious  obstacle  in  the  treatment  of  dis- 
eased air-passages,  and  proper  attention  to  diet  and  the 
function  of  the  bowels  is  not  rarely  the  first  step  in  the 
road  to  success.  In  chronic  constipation  which  does  not 
yield  to  fruit  and  exercise,  enemata  of  hot  water  prove 
more  serviceable  in  the  end  than  the  habitual  use  of 
laxatives. 

The  discomfort  due  to  a  given  degree  of  nasal  disease 
is  to  some  extent  an  index  of  the  condition  of  the  nervous 
system.  Thus,  for  instance,  chronic  suppuration  of  the 
accessory  cavities  need  not  give  rise  to  much  actual  suf- 
fering in  subjects  with  vigorous  nervous  system,  whereas 
in  neurasthenic  conditions  such  processes  may  cause  con- 
siderable pain  in  the  form  of  headache  and  neuralgia. 
The  tone  of  the  nervous  system  is  also  indicated  strikingly 
by  the  vascular  irritability  in  the  nose  and  the  so-called 
reflex  disturbances  thereby  engendered  in  those  cases  in 
which  there  is  enlargement  of  the  cavernous  plexus  in  the 
nasal  lining.  Thus  it  is  not  uncommon  to  see  these  dis- 
turbances intensified  during  pregnancy.  In  such  instances 
more  can  often  be  accomplished  therapeutically  by  advice 
from  the  standpoint  of  the  neurologist  than  by  treatment 
limited  to  the  nose,  although,  of  course,  both  lines  of 
therapeutics  should  be  considered. 

17.  From  an  etiologic  point  of  view  the  habits  of  the  in- 
dividual must  not  be  ignored.  It  can  be  readily  observed 
that  smoking  tobacco  irritates  and  increases  the  secretion 
in  affections  of  the  posterior  parts  of  the  nose  and  of  the 
throat.  The  difference  is  promptly  noticeable  if  the 
patient  reduces  his  allowance  of  tobacco,  especially  if 
this  is  used  in  the  form  of  cigarettes.  If  he  can  restrict 
himself  within  the  limits  of  two  or  three  cigars  daily,  or 
their  equivalent  in  the  pipe,  it  is  generally  unuecessar\' 
to  insist  on  total  abstinence.  There  is,  however,  one 
form  of  pharyngeal  disease  in  the  etiology  of  which 
smoking  plays  a  greater  role  than  in  any  other  affection. 
It  is  the  diffuse  chronic  pharyngitis,  usually  dependent,  in 


AGE.  49 

the  first  place,  upon  nasal  stenosis  or  nasal  suppuration, 
and  characterized  by  thickening  and  uniform  injection  of 
the  pharyngeal  wall,  and  especially  its  adenoid  elements, 
the  tonsils  and  strands  of  lymphatic  tissue  behind  the 
posterior  pillars.  In  this  form  the  throat  is  very  sensi- 
tive to  mechanical  contact.  According  to  personal  expe- 
rience, this  form  of  pharyngitis  occurs  mainly — though 
not  quite  exclusively — in  smokers,  and  necessitates  total 
abstinence  for  relief.  Alcoholic  excesses,  too,  may  have 
some  share  in  the  etiology  of  this  pharyngitis.  The 
morning  vomiting  of  hard  drinkers  is  often  dependent  on 
this  diffuse  pharyngitis;  sometimes,  however,  it  is  due  to 
chronic  inflammation  of  the  lingual  tonsil.  Attention 
has  also  been  called  to  the  injurious  influence  that  the 
drinking  of  very  hot  fluids  may  exert  upon  the  pharynx. 

Inflammatory  disease  of  the  upper  air-passages  is  also 
engendered  and  maintained  by  exposure  to  irritating  dust 
and  acrid  gases.  Workmen  employed  in  lime,  cement, 
arsenic,  and  especially  chrome  works  frequently  suffer 
from  ulceration  of  the  nasal  septum. 

l8.  Age  is  an  important  factor  in  the  predisposition  to 
different  ailments  of  the  upper  respiratory  passages.  Al- 
though all  ages  are  equally  liable  to  acute  coryza  as  well 
as  chronic  purulent  rhinitis,  suppuration  of  the  sinuses  is 
rarely  seen  clinically  in  young  children,  and,  indeed,  not 
often  under  the  age  of  puberty,  although  anatomically 
it  has  been  demonstrated  frequently  in  connection  with 
infectious  diseases  of  the  upper  air-passages.  The  acces- 
sory cavities  are  but  poorly  developed  until  after  the 
seventh  year.  Septum  deformities,  too,  are  uncommon 
in  childhood,  especially  crests  and  spurs,  while  deflec- 
tions may  occur  before  the  second  dentition,  although 
they  are  infrequent.  Hypertrophies  of  the  nasal  mucous 
membrane,  in  particular  polypi,  are  rare  lesions  in  child- 
hood. This  is  one  of  the  reasons  why  children  are 
almost  exempt  from  postnasal  catarrh.  Atrophic  rhinitis 
(ozena),  on  the  contrary,  usually  begins  early  in  life. 

The  lymphatic  structures  in  the  pharynx  do  not  grow 


50  NASAL   AND    PHARYNGEAL    DISEASES. 

morbidly  after  the  first  three  or  four  years  of  life,  unless 
hypertrophy  had  begun  previous  to  that  time.  After 
puberty  the  morbidly  enlarged  tonsils,  especially  the 
pharyngeal  tonsil,  may  recede  moderately.  When  en- 
larged, they  give  rise  to  more  annoyance  during  child- 
hood than  in  later  life,  partly  because  pharyngeal  and 
tonsillar  inflammations  are  more  especially  an  ailment  of 
childhood  and  adolescence,  and,  in  part,  because  the 
lymphatic  structures  become  more  fibrous  and  less  vascu- 
lar in  the  course  of  years.  Infectious  diseases  localized 
in  or  involving  the  upper  air-passages,  such  as  diphtheria 
and  the  eruptive  fevers,  become  less  and  less  common  as 
early  childhood  is  passed. 


CHAPTER   III. 

SYMPTOMATOLOGY;  METHODS  OF  EXAMINATION 
AND  APPEARANCES  OF  NOSE  AND  PHARYNX; 
METHODS  OF  TREATMENT  IN  NASAL  AND  PHA- 
RYNGEAL AFFECTIONS. 

19.  Subjective  Symptoms.— Pain — Most  nasal  dis- 
eases do  not  cause  pain.  Abscess  of  the  septum  and 
gummatous  tumors  under  the  periosteum  may,  however, 
give  rise  to  severe  suffering,  the  pain  not  being  correctly 
localized,  but  described  as  headache.  In  neurasthenic 
persons  various  nasal  diseases  may  be  attended  with 
much  discomfort,  especially  in  the  form  of  diffuse  head- 
ache, while  neuralgia  of  the  supra-orbital  or  infra- 
orbital nerves,  sometimes  of  great  severity,  can  be  caused 
by  inflammation  of  the  accessory  sinuses.  Acute  inflam- 
mation of  any  of  the  structures  in  the  pharynx  is  always 
painful,  particularly  during  swallowing,  and  to  a  degree 
commensurate  with  the  intensity  of  the  disease.  If  the 
upper  part  of  the  faucial  tonsil  or  the  recess  tehind  the 
posterior  pillar  of  the  fauces  is  involved,  the  pain  is  said 
to  shoot  into  the  ear.  In  chronic  pharyngeal  inflamma- 
tions patients  describe  the  sensation  less  as  pain,  but 
rather  as  an  irritation  or  tickling. 

20.  The  most  common  complaint  of  patients  with 
nasal  disease  is  obstruction  of  the  nasal  passage.  This  may 
be  present  at  all  times — if  due  to  a  structural  narrowing 
of  the  nasal  caliber — or  transient,  if  caused  by  temporary 
distention  of  the  vascular  plexus  in  the  mucous  mem- 
brane or  by  the  presence  of  viscid  secretion.  The  stuffy 
feeling  may  be  limited  to  one  side  of  the  nose  or  may 
exist  on  both,  while  if  due  to  excessive  vascularity,  it 
often  passes  abruptly  from  one  side  to  the  other.  Nasal 
obstruction  is  also  very  characteristic  of  any  encroach- 

61 


52  NASAL    AND    PHARYNGEAL   AFFECTIONS. 

ment  upon  the  capacity  of  the  vault  of  the  pharynx  by 
enlargement  of  the  pharyngeal  tonsil  or  by  a  retropharyn- 
geal abscess,  even  if  the  nasal  passages  themselves  are 
clear.  This  obstruction,  too,  is  intensified  when  the 
vascularity  is  increased  by  the  reclining  position.  Hence 
during  sleep  mouth-breathing  occurs,  even  if  nasal  res- 
piration is  possible  during  waking  hours.  Whenever 
the  tongue  is  arched  during  mouth-breathing  so  as  to 
leave  merely  a  narrow  passage  between  itself  and  the 
soft  palate,  the  current  of  air  starts  vibration  of  the  soft 
palate  and  causes  snoring. 

The  patency  of  the  nasal  passages  can  be  gauged 
objectively  by  the  sound  produced  by  breathing.  The 
air  passes  through  a  normal  nose  both  during  inspiration 
and  expiration  without  any  sound  whatever,  except  when 
a  most  forcible  effort  is  made.  In  proportion  to  the 
narrowness  of  the  passage  breathing  yields  a  rustling  or 
whistling  noise.  In  order  to  test  one  side  at  a  time  the 
other  side  of  the  nose  must  be  closed  with  the  thumb 
without  pressure  on  the  flexible  septum. 

Interference  with  nasal  respiration  is  also  indicated 
by  the  nasal  "twang"  of  the  voice.  The  voice  is  not 
affected  by  a  one-sided  obstruction  if  the  other  side  is 
entirely  clear,  but  whenever  both  halves  of  the  nose  are 
narrowed,  the  normal  resonance  of  speech  is  changed 
and' the  voice  sounds  "dead."  The  most  characteristic 
change  in  the  voice  is  found  with  enlarged  pharyngeal 
tonsil. 

2T.  Nasal  Secretions. — In  the  normal  condition  the 
nasal  mucus  is  never  secreted  in  sufficient  quantity  to 
require  removal  either  by  blowing  the  nose  or  by  aspira- 
tion into  the  pharynx.  Hence  whenever  there  is  any 
discharge  from  the  nose  it  is  an  abnormal  occurrence. 
The  dischargee  is  glairv,  clear  mucus  if  due  to  mechanical 
or  chemical  irritation  of  a  non-inflamed  mucous  mem- 
brane, but  more  or  less  turbid,  or  pure  pus,  if  caused  by 
inflammation.  The  secretion  from  the  rear  third  of  the 
nasal  passage  is  blown  out  only  with  difficulty,  but  either 


METHODS    OF    EXAMINATION    OF    THE    NOSE.  53 

drops  into  the  pharynx  from  time  to  time,  or  is  drawn 
back  by  forcible  inspiration.  Discharge  from  the  nasal 
sinuses  may  also  drop  into  the  throat  under  some  cir- 
cumstances, especially  in  the  recumbent  position.  If 
scant  nasal  discharge  dries  in  the  form  of  crusts,  the 
patients  will  sometimes  remove  them  only  at  long  inter- 
vals. If  inspection  does  not  satisfy  the  surgeon  as  to  the 
kind  or  quantity  of  discharge,  the  douche  can  be  used 
(see  1  25),  whereupon  any  nasal  secretion  can  be  seen 
floating  in  the  basin. 

Purulent  nasal  secretion  has  a  pronounced  odor  only 
if  pent  up  and  decomposed  or  dried  in  the  form  of  crusts. 
The  two  most  characteristic  odors  are  those  of  ozena  and 
of  syphilitic  necrosis,  which  may  enable  an  expert  to 
make  a  diagnosis.  Foul,  too,  but  different  is  the  odor  in 
'  sinus  suppuration  with  retained  pus  and  in  concretions 
and  foreign  bodies.  In  any  form  of  nasal  obstruction 
with  secretion  the  breath  through  the  mouth  is  likely  to 
be  offensive,  especially  on  awakening. 

22.  Sneezing  is  a  normal  reflex  action  whenever  the 
nasal  lining  is  irritated.  It  is  a  prominent  symptom 
during  acute  nasal  catarrh  so  long  as  the  nose  is  not  en- 
tirely occluded.  In  chronic  nasal  diseases  sneezing,  some- 
times in  uncontrollable  fits,  is  an  annoying  feature  in 
proportion  to  the  "nervous"  disposition  of  the  patient. 
It  occurs  least  whenever  the  mucous  membrane  is  either 
much  hypertrophied  or  atrophied. 

Coughing  is  not,  as  a  rule,  produced  by  nasal  disease, 
but  may  accompany  pharyngeal  lesions,  especially  hyper- 
trophy of  the  adenoid  tissue  at  the  root  of  the  tongue. 
The  cough  of  pharyngeal  patients  is,  however,  commonly 
due  to  extension  of  the  disease  into  some  of  the  struc- 
tures of  the  larynx  or  to  coexisting  bronchitis. 

23.  Methods  of  Examination  of  the  Nose. — The  ob- 
jective examination  begins  with  the  external  shape  of  the 
nose.  A  flattened  bridge  is  often  seen  in  patients  with 
ozena.  Decided  sinking  in  of  the  bridge  of  the  nose  is 
due  to  cicatricial  shrinkage  of  the  septum,  almost  always 


54  NASAL   AND    PHARYNGEAL   AFFECTIONS. 

the  result  of  syphilis,  either  acquired  or  inherited.  De- 
flection of  the  nose  to  one  side  indicates  asymmetry  of 
the  septum,  caused  either  by  unequal  growth  or  by  an 
injury.  On  watching  the  alae  nasi  during  forcible  inspi- 
ration it  is  to  be  noted  whether  they  remain  normally 
rigid  or  collapse  and  are  drawn  in  with  every  breath, 
thereby  indicating  obstruction. 

In  order  to  see  the  interior  of  the  nose  light  must  be 
thrown  in.  This  is  done  with  a  concave  mirror  with  a 
central  perforation  through  which  the  surgeon  looks. 
The  mirror  is  held  in  the  hand  or  is  attached  by  means 
of  a  ball-and-socket  joint  to  a  strap  around  the  forehead 
or  to  a  metallic  spring  clasping  the  head.  There  are 
some  handles  made  that  may  be  held  between  the  teeth. 
The  source  of  light  should  be  the  strongest  one  available. 
Sunlight  can  be  used  advantageously,  with  a  plane  mir-  * 
ror  in  summer  to  avoid  burning.  The  light  from  bright 
white  clouds  is  perhaps  the  best  of  any.  A  blue  sky 
gives  an  insufficient  light.  Of  all  artificial  lights  the 
Welsbach  incandescent  burner  is  the  whitest,  but  any 
gas-jet,  preferably  an  Argand  burner,  or  a  broad  kerosene 
flame  will  answer.  Of  electric  lights,  one  with  spirally 
wound  filament  is  the  best.  The  various  forms  of  con- 
densers placed  in  the  market  offer  no  practical  advantage 
over  the  naked  flame.  If  artificial  light  is  used,  the  eye 
is  more  sensitive  when  daylight  is  excluded  by  window- 
shades. 

A  very  convenient  arrangement  is  an  electric  headlight, 
of  which  various  forms  are  in  the  market  (Fig.  ii).  A 
6  or  8  candle-power  miniature  lamp  inclosed  within  a 
tube  with  condenser  lens  is  attached  to  the  forehead  just 
above  the  eye.  This  is  connected  by  means  of  a  flexible 
and  easily  detachable  cord  to  the  source  of  electricity. 
A  street  current  of  not  over  no  volts  is  the  most  con- 
venient source  of  energy  if  its  intensity  is  suitably 
reduced  by  a  proper  resistance  in  the  form  of  a  wall- 
lamp  furnished  by  the  maker.  An  additional  device 
found  by  the  author  to  be  useful  is  that  of  putting  a 


METHODS    OF    EXAMINATION    OF   THE    NOSE. 


55 


resistance  (a  lamp  of  210  ohms)  into  the  same  circuit  as  a 
(parallel)  shunt,  whereby  the  shock  felt  by  the  hand 
when  the  exposed  metallic  connectors  are  touched  is 
reduced  to  a  minimum.  If  no  street  current  is  available, 
resort  must  be  had  to  a  battery  or  a  storage-cell,  which 
requires  attention   and   gives   rise  to  some   annoyance. 


Fig.  II. — Electric  head-light. 

With  the  electric  head-lamp  the  observer  is  more  at 
liberty  to  move  his  head  than  when  he  reflects  the  light 
by  means  of  a  mirror. 

It  is  rarely  possible  to  see  any  distance  into  a  nose 
without  separating  the  flexible  walls  of  the  vestibule  by 
means  of  a  speculum.  Additional  space  is  gained  by 
raising  the  tip  of  the  nose  by  upward  pressure.  A  bi- 
valve speculum  (Fig.  12)  can  be  handled  with  the  least 


Fig.  12. — Pynchon's  bivalve  nasal  speculum. 

annoyance  to  the  patient,  and,  on  account  of  the  broad- 
ness of  its  blades  and  the  control  that  the  hand  can  exert 
over  it,  it  permits  the  most  satisfactory  view.  It  has  the 
disadvantage,  however,  of  not  being  self-retaining,  a  re- 
quisite in  most  operations.  Of  the  various  spring  .specula, 
the  author  has  found  Goodwillie's  (Fig.  13)  and  Palmer's 


56  NASAL    AND    PHARYNGEAL    AFFECTIONS. 

(Fig.  14)  the  most  convenient.  Wire  specula  do  not 
cover  the  hairs  in  the  vestibule,  which,  in  some  cases, 
interfere  with  the  view  and  require  clipping. 

In  small  children  the  nose  can  be  viewed  through  an 
ear-speculum. 

The  view  into  the  interior  of  the  nose  begins  with  the 
vestibule — the  space  within  the  external  part  of  the  nose. 
The  alae  nasi  are  lined  by  true  skin  with  more  or  less 
hairs  (vibrissae),  whereas  on  the  septum  the  skin  changes 
into  mucous  membrane  within  a  few  millimeters  above 
its  inferior  edge  and  behind  its  front  end.  Erosions  are 
sometimes  found  at  the  junction  of  the  septum  and  ex- 
ternal nose.  The  septum  is  normally  straight,  but  may 
be  deviated  morbidly  more  or  less  to  one  side.  The  lower 
rim  of  the  triangular  cartilage  of  the  side  of  the  nose 


Fig.  13. — Goodwillie  s    nasal   speculum.         Fig.  14. — Palmer's   self-retaining 

nasal  speculum. 

projects  into  the  interior  of  the  vestibule  in  the  form  of  a 
skin-covered  prominent  fold  narrowing  the  entrance  into 
the  nasal  passage  (compare  Fig.  2). 

The  nasal  cavities  proper  are  the  irregularly  shaped 
passages  between  the  nasal  septum  and  the  external  walls. 
They  begin  at  the  pyriform  aperture  bounded  by  the 
sharp  edge  of  the  rnaxillary  bones,  and  end  with  the  pos- 
terior choanae.  Their  length  varies  from  50  to  75  mm. 
in  the  adult,  the  width  of  the  two  sides  together,  meas- 
ured between  the  external,  walls  along  the  floor,  from  29 
to  42  mm.,  the  total  height  from  floor  to  roof,  from  38  to 
50  mm.  They  are  lined  by  mucous  membrane  normally 
of  a  light  grayish-red  or  pink  color. 

Each  nasal  half  is  bounded  on  the  median  side  by  the 
septum.  When  this  is  perforated  pathologically,  the  view 


METHODS    OF    EXAMINATION    OF   THE    NOSE. 


57 


extends  into  the  other  side  of  the  nose.  The  septum  is 
not,  as  a  rule,  an  ideal  straight  wall.  In  its  anterior 
upper  portion  the  tuberculum  of  the  septum  forms  a 
more  or  less  projecting  tumefaction.  The  examiner  must 
note  whether  any  existing  projecting  irregularities  along 
the  septum  encroach  sensibly  upon  the  nasal  caliber  or 
extend  even  far  enough  to  touch  the  lateral  wall.  The 
surface  of  the  septum  may  be  smooth,  and  yet,  by  the 
convexity  of  an  asymmetric  position,  the  one  half  of  the 
nose  may  be  narrowed,  the  other  perhaps  widened.  By 
successive  examinations  of  the  two  sides  it  is  ascertained 
whether  an  asymmetric  septum  is  merely  curved  or  bent 
angularly  or  is  absolutely  thickened.     When  the  septum 


Fig.  15. — View  into  the  normal  right  nasal  passage  through  the  wire  speculum, 
showing  the  inferior  and  the  front  end  of  the  middle  turbinal. 

is  straight,  the  view  extends  to  the  rear,  so  that  with 
sufficient  illumination  the  posterior  wall  of  the  upper 
pharynx  can  be  seen.  The  view  upward  is  terminated 
usually  by  the  narrow  chink  between  the  middle  turbin- 
ated body  and  the  septum.  The  upper  turbinated  process 
is  not  visible  (Fig.  15). 

The  floor  of  each  nasal  passage  is  smooth,  without 
landmarks.  The  external  wall  presents  the  most  varied 
and  variable  architecture,  on  account  of  its  horizontal 
projecting  ledges,  the  turbinated  processes  or  turbinals. 
On  anterior  inspection  only  the  inferior  and  middle  tur- 
binals are  visible.  The  space  underneath  the  former  is 
the  inferior  meatus  ;  that  between  inferior  and  middle 
turbinal  is  called  the  middle  meatus  of  the  nose.     The 


58  NASAL   AND    PHARYNGEAL    AFFECTIONS. 

inferior  turbinated  body  forms  an  overhanging  cornice 
reaching  nearly  to  the  floor.  Any  undue  obliquity  or 
projection  of  this  ledge  narrows  the  respiratory  passage. 
Even  with  normal  architecture  of  the  bone  the  inferior 
turbinal  may  obstruct  the  space  by  reason  of  distention 
of  its  venous  plexus  or  hypertrophy  of  its  mucous  mem- 
brane. The  swelling,  if  due  to  the  former  condition, 
can  be  indented  with  the  probe,  but  this  is  not  the  case 
if  it  is  dependent  on  thickening  of  the  mucous  mem- 
brane. The  vascular  tumefaction  disappears  upon  the 
application  of  cocain,  which  does  not  change  the  appear- 
ance of  the  thickened  mucous  membrane.  In  atrophic 
rhinitis  the  ledge  formed  by  the  inferior  turbinal  is  more 
or  less  reduced  in  size.  The  space  between  the  inferior 
and  middle  turbinated  bodies  is  variable  in  height. 

The  middle  turbinal  is  a  ledge  that,  by  reason  of  its 
curving,  hangs  down  to  a  variable  extent.  The  distance 
between  the  vestibule  and  the  front  end  of  the  middle 
turbinated  body  is  also  subject  to  much  variation.  Its 
anterior  end  is  sometimes  broadened  by  expansion  of  its 
bony  frame. 

The  mucous  membrane  covering  the  middle  turbinal 
is  not  freely  movable,  since  there  exists  no  well-defined 
vascular  plexus  in  it.  It  is  only  when  it  is  hypertrophied 
that  it  can  be  moved  to  and  fro  by  the  probe.  The  im- 
portant space  where  the  maxillary  and  frontal  sinuses 
communicate  with  the  nasal  cavity  through  openings  in 
the  external  wall  of  the  nose  is  completely  hidden  from 
view  by  the  middle  turbinal.  The  rear  ends  of  inferior 
and  middle  turbinated  bodies  can  generally  not  be  well 
defined  in  the  anterior  rhinoscopic  view.  The  color  of 
the  nasal  mucous  membrane  is  a  pale  pink.  A  red  tint 
indicates  inflammation. 

If,  in  a  nasal  examination,  the  view  is  obstructed  by 
general  congestion  of  the  mucous  membrane  or  by  en- 
gorgement of  normal  or  abnormally  situated  cavernous 
tissue,  a  spray  of  cocain  solution,  2  per  cent,  to  4  per 
cent,  in  strength,  or  of  suprarenal  solution  will  cause 


METHODS    OF    EXAMINATION    OF    THE    PHARYNX.  59 

suiBcient  contraction  of  the  blood-vessels  to  permit  a 
subsequent  reexamination  at  better  advantage. 

34.  Methods  of  :Exainination  of  the  Pharynx. — 
While  proceeding  to  the  examination  of  the  pharynx  the 
examiner  should  note  the  appearance  of  the  mouth.  Ca- 
rious teeth,  especially  those  back  of  the  cuspids,  are  not 
a  rare  cause  of  suppuration  of  the  maxillary  sinus,  while 
sensitive  teeth,  especially  molars  or  erupting  wisdom 
teeth,  may  cause  neuralgia  referred  to  the  ear.  Some  in- 
ference may  be  made  relative  to  the  shape  of  the  nasal 
fossae  from  the  shape  of  the  roof  of  the  mouth.  An 
asymmetric  palate  implies  asymmetry  of  the  nasal  sep- 
tum. A  high  palatal  vault  is  often,  but  not  always, 
indicative  of  stenosis  of  the  nasal  passages  or  obstruction 
of  the  upper  pharynx.  Unusual  length  of  the  uvula  is 
of  significance  only  if  it  causes  the  uvula  to  rest  upon 
and  thereby  irritate  the  root  of  the  tongue.  Slight 
asymmetry  of  the  uvula  may  be  normal,  but  its  adhesion 
to  one  side  is  due  to  scars  following  syphilitic  ulceration 
or  diphtheria. 

Coating  of  the  tongue,  if  not  referable  to  disease  of  the 
teeth  or  of  the  stomach  or  to  an  acute  disturbance,  sug- 
gests mouth-breathing. 

The  normal  tonsils  are  practically  invisible  except  on 
'gagging"  or  on  retraction  of  the  anterior  pillar  with  a 
blunt  hook.  They  consist  of  a  thin  and  scarcely  project- 
ing layer  of  adenoid  tissue  with  minute  crypts,  between 
the  anterior  and  posterior  pillars  of  the  palate.  Every 
visible  prominence  of  this  structure  means  morbid  over- 
growth Existing  inflammation  of  the  tonsillar  tissue  is 
shown  by  any  redness  differing  in  hue  from  that  of  the 
adjoining  mucous  membrane.  Within  the  crypts  of  the 
enlarged  tonsil  there  may  be  concretions  that  may  or  may 
not  be  visible.  If  their  presence  is  suspected,  they  may 
be  squeezed  out  by  pressure  with  a  blunt  rod  or  by  insert- 
ing a  blunt  hook  into  the  crypts.  From  one  tonsil  to  the 
other  there  extends  a  bridge  of  adenoid  tissue  along  the 
root  of  the  tongue  in  front  of  the  epiglottis,  called  the 


6o  NASAL    AND    PHARYNGEAL   AFFECTIONS. 

fourth  or  lingual  tonsil.  It  consists  of  a  row  of  small 
papules,  each  about  3  mm.  high,  with  central  crypts. 
The  lingual  tonsil  can  be  seen  only  with  difficulty  by 
pulling  out  the  tongue,  but  it  can  easily  be  examined  by 
means  of  the  inverted  rhinoscopic  mirror. 

It  is  often  hypertrophied  by  reason  of  chronic  inflam- 
mation, while  its  pronounced  atrophy  suggests  the  exist- 
ence of  old  syphilis. 

The  pharynx  may  be  compared  to  a  somewhat  flattened 
tube,  the  upper  end  of  which  is  closed  by  a  half-dome- 
shaped  roof  that  slopes  gradually  into  the  posterior  wall. 
It  ends  below  at  the  level  of  the  larynx  underneath  the 
root  of  the  tongue.  Its  anterior  side  is  incomplete.  Above 
the  palate  this  is  formed  by  the  plane  of  the  posterior 
choanse,  which  plane  slopes  forward  and  downward. 
Underneath  the  choanae  is  the  soft  palate,  forming  a 
horizontal  diaphragm  anteriorly,  but  which  curves  pos- 
teriorly, when  relaxed,  so  as  to  hang  down  like  a  curtain. 
The  posterior  surface  of  the  pendant  portion  of  the  palate 
thus  forms  a  part  of  the  anterior  boundary  of  the  phar- 
ynx. Below  this  is  the  communication  between  mouth 
and  pharynx,  while  the  curve  of  the  root  of  the  tongue 
forms  the  lowest  part  of  the  imaginary  anterior  wall  of 
the  pharynx. 

The  posterior  wall  of  the  lower  pharynx  is  seen  only 
when  the  tongue  is  depressed.  If  the  subject  cannot  do 
this  naturally,  the  surgeon  must  use  a  tongue  depressor. 
This  should  be  of  heavy  steel,  in  order  not  to  be  bent  by 
an  unruly  tongue.  The  simplest  shape,  two  rigid  plates 
at  right  angles,  of  which  the  one  for  the  tongue  is  per- 
forated to  increase  its  hold,  is  better  than  a  more  com- 
plicated instrument  (Fig.  16).  The  examination  can  be 
made  in  a  good,  direct  light  opposite  a  window,  or  light 
may  be  thrown  in  with  the  mirror.  The  more  the  lips 
are  retracted,  the  better  the  view.  Turning  of  the  head 
to  either  side  may  simulate  asymmetry  of  the  pharynx. 

If  the  person  gags  during  the  examination,  the  tonsils 
are  pushed  forward  and  toward  the  median  line  by  the 


METHODS  OF  EXAMINATION  OF  THE  PHARYNX.      6 1 

action  of  the  constrictor  muscles  of  the  pharynx.  Dur- 
ing this  movement  they  encroach  upon  the  cavity  much 
more  than  when  in  their  normal  position,  and  that  part  of 
their  mass  which  is  ordinarily  hidden  by  the  pillars  of  the 
fauces  is  thereby  well  shown. 

The  normal  pharyngeal  surface  is  a  pale  pink.  Ex- 
treme pallor  indicates  anemia;  lividity,  on  the  other 
hand,  suggests  venous  stasis,  possibly  due  to  heart  dis- 
ease. Enlarged  veins  are  the  result  of  chronic  irritation, 
not  uncommonly  from  smoking.  Diffuse  redness  signi- 
fies inflammation.  In  chronic  troubles  the  vascularity 
may  increase  during  the  examination.     Red  and  slightly 


Fig.  1 6. — Bos  worth's  tongue  depressor. 

raised  follicles  of  lymphatic  tissue  are  not  normal  struct- 
ures, and  the  same  may  be  said  of  strands  of  injected 
lymphatic  tissue  at  the  junction  of  the  posterior  and  lateral 
walls  of  the  pharynx.  These  lateral  lymphatic  strands 
are,  in  rare  instances,  hypertrophied  in  the  form  of  pro- 
jecting wings.  The  normal  pharynx  is  not  covered  with 
secretion.  Lumps  of  mucus  or  crusts  of  dried  pus  are  the 
results  of  disease,  but  the  lesion  is  more  likely  to  be  in 
the  nasal  passage  or  at  the  roof  of  the  pharynx  than  in 
its  lower  part. 

In  order  to  view  the  region  above  the  palate  a  rhino- 
scopic  mirror  must  be  placed  behind  the  posterior  pillars 
of  the  fauces  at   such  angles  that  it  gives  successively 


62  NASAL    AND    PHARYNGEAL   AFFECTIONS. 

images  of  the  upper  part  of  the  pharynx  and  of  the  poste- 
rior nasal  choanae.  The  mirror  is  at  once  clouded  by  the 
moisture  of  the  breath,  unless  it  is  either  warmed  a  trifle 
above  the  body-temperature  or  soaped.  A  film  of  soap, 
by  itself  invisible,  remaining  after  gentle  wiping  with  a 
cloth,  prevents  deposition  of  dew.  The  mirrors  vary  in 
diameter  from  i  to  3  cm.,  and  are  fastened  on  the  handle 
at  an  angle  of  45  degrees.  The  larger  the  mirror  that  can 
be  tolerated,  the  better  will  be  the  illumination  and  the 
more  extensive  the  view.  But  it  is  not  possible  to  see 
all  structures  at  a  single  glance  with  any  mirror,  and  it 
requires  tilting  in  various  directions  and  shifting  of  the 
examiner's  head  in  order  to  bring  them  successively  into 
view.  As  the  light  is  weakened  by  its  double  reflection, 
the  examination  is  more  satisfactory  the  stronger  the 
illumination.  Sunlight  is  by  far  the  best.  It  is,  of 
course,  necessary  to  throw  the  light  in  the  direction  of 
the  glance  through  the  central  hole  in  the  mirror. 

An  expert  can  make  a  satisfactory  examination  with  a 
rhinoscopic  mirror  in  perhaps  one-third  of  all  patients  at 
first  trial.  A  few  patients  can  never  be  examined — viz., 
those  who  oppose  the  surgeon  from  fear.  This  applies  to 
adults  as  well  as  to  children.  The  younger  the  child,  the 
more  difficult  is  it  to  overcome  its  fear,  but  sometimes, 
even  in  children  as  young  as  three  years  of  age,  the  roof 
of  the  pharynx  can  be  seen  fairly  well.  As  soon  as  the 
patient  fears  the  instrument  he  gags  and  thereby  brings 
the  soft  palate  and  the  pharyngeal  walls  into  contact, 
thus  rendering  the  examination  impossible.  Sometimes 
this  is  due  to  actual  irritability  of  the  pharyngeal  surface, 
especially  in  the  chronic  inflammation  of  smokers  and 
drinkers.  More  commonly,  however,  the  pharyngeal  move- 
ments are  of  psychic  origin,  and  can  be  seen  to  begin 
when  the  mirror  is  approached  and  before  it  touches 
the  mucous  membrane.  Many  patients  can  be  induced 
to  submit  by  persuasion.  Sometimes  it  requires  a  few 
sittings  to  train  them.  When  the  resistance  is  due  to 
sensitiveness  of  the  pharynx,  a  10  per  cent,  solution  of 


METHODS    OF    EXAMINATION    OF    THE    PHARYNX.  63 

cocain  brushed  on  the  pillars,  pharynx,  and  soft  palate 
may  render  the  examination  possible.  On  account  of  its 
unpleasant  taste  this  should  not  be  used  needlessly.  The 
view  is  more  sweeping  if  the  soft  palate  is  pulled  forward 
with  a  palate  hook  (Fig.  17).  If  the  pharynx  is  nar- 
row in  the  anteroposterior  direction,  the  use  of  the  hook 
may  be  a  necessity.  The  hook,  however,  does  not  reduce 
the  patient's  sensitiveness,  although  it  is  often  as  well 


Fig.   17. — Tornwald's  palate  hook. 

tolerated  as  the  mirror  itself.  During  gagging  the  hook 
affords  no  assistance  to  the  examiner.  For  operations  a 
self-retaining  palate  hook  is  often  serviceable  (Fig.  18). 
Just  as  serviceable  as  a  palate  hook,  but  also  equally  as  dis- 
agreeable, is  the  retraction  of  the  palate  by  means  of  rub- 
ber tubing.  A  drainage-tube  3  or  4  mm.  thick  and  about 
30  mm.  long  is  pushed  through  the  nostril  and  seized  in  the 
pharynx  with  forceps,  pulled  through  the  mouth,  and  its 


Fig.   18. — Hoffman's  self-retaining  palate  hook.     The  elastic  traction  is  made 
by  rubber  bands. 

ends  are  tied  over  the  upper  lip.  Under  all  circumstances 
the  examination  must  be  made  with  gentleness,  and  con- 
tact with  the  mirror  with  the  walls  is  to  be  avoided. 
Like  all  physical  examinations,  the  use  of  the  rhinoscopic 
mirror  requires  much  practice  before  the  surgeon  can 
have  command  of  it. 

A  part  of  the  posterior  wall  of  the  nasopharynx  and 
sometimes  even  its  entire  extent  up  to  the  posterior  lip 


64  NASAL   AND    PHARYNGEAL   AFFECTIONS. 

of  the  Eustachian  orifice  is  visible  to  direct  inspection 
without  mirror,  when  the  patient  throws  the  head  back, 
while  the  palate  is  pulled  forward  firmly  with  a  palate 
hook,  provided  the  patient  does  not  gag.  The  mouth 
must  be  opened  as  wide  as  possible  to  permit  the  surgeon 
to  look  up. 

In  the  rhinoscopic  image  the  posterior  wall  of  the 
pharynx  can  be  traced  up  to  its  sloping  junction  with 
the  roof  (Fig.  19).  The  slope  varies  in  different  heads. 
The  transverse  width  of  the  pharynx  is  narrowed  above 
the  palate  by  the  projecting  lips  of  the  Eustachian  tubes, 


Fig.  19. — Postrhinoscopic  view  of  the  septum,  choanse,  Eustachian  tubes,  soft 
palate,  and  pharynx  vault. 

while  above  and  behind  them  are  the  recesses  known  as 
the  fossae  of  Rosenmiiller.  The  more  the  elevation  of  the 
Eustachian  tube  projects,  the  deeper  are  the  fossae.  They 
may  be  obliterated  partly  by  hypertrophied  lymphatic 
tissue.  The  vault  or  roof  of  the  pharynx  ends  anteriorly 
at  the  upper  rim  of  the  posterior  choanse.  The  central 
area  of  the  upper  posterior  wall  is  the  site  of  the  pharyn- 
geal tonsil.  This  cushion  of  submucous  adenoid  tissue 
does  not  project  normally  beyond  the  plane  of  the  sur- 
rounding surface.  Whenever  it  forms  a  distinct  tume- 
faction,  it   must   be    called   hypertrophied.     Its   normal 


METHODS  OF  EXAMINATION  OF  THE  PHARYNX.      65 

color  is  slightly  redder  than  that  of  the  posterior  wall 
below  it.  In  children,  and  somewhat  less  markedly  in 
normal  adults,  the  pharyngeal  tonsil  presents  from  five  to 
seven  slightly  prominent  sagittal  ridges.  During  the 
earlier  stage  of  morbid  hypertrophy  this  ridged  and  fur- 
rowed appearance  is  exaggerated  in  the  form  of  cocks- 
comb-shaped growth.  At  a  later  period  the  enlarged 
mass  becomes  smooth  in  surface.  As  the  normal  tonsil  is 
at  least  from  5  to  8  mm.  behind  the  rim  of  the  choanae, 
the  obliquity  of  the  mirror  image  gives  the  appearance 
as  if  this  clear  space  were  a  vertical  anterior  wall  above 
the  choanae,  which  in  reality  does  not  exist.  The  mor- 
bidly enlarged  tonsil  appears  in  the  mirror  at  least  flush 
with  the  rim  of  the  choanae,  but  may  even  hide  a  large 
part  of  the  posterior  nasal  orifice  from  view.  Near  the 
lower  or  posterior  end  of  the  tonsil  and  in  or  near  the 
median  line  there  is  sometimes  seen  a  small  pit — the  so- 
called  pharyngeal  bursa. 

The  dimensions  of  the  pharynx  are  governed  by  the 
variable  size  of  the  bony  rim  of  the  posterior  choanae. 
Zuckerkandl  states  this  as — 

In  the  Adult.  New  Born. 

Maximum  width  of  each  opening 20  mm.  7  mm. 

Minimum  width  of  each  opening 13    "  6    " 

Maximum  height 39    "  9    " 

Minimum  height 25    "  7    " 

But  as  the  posterior  choanal  rim,  parallel  with  the  edge 
of  the  vomer,  slopes  upward  and  backward,  the  actual 
vertical  height  of  the  pharynx  is  less  than  the  former 
figure,  averaging  about  20  mm.  in  the  adult.  The 
anteroposterior  depth  is  least  next  to  the  sloping  roof, 
and  greatest  at  the  level  of  the  inferior  choanal  rim. 
The  obliquity  of  the  choanal  plane  is  not  recognizable  in 
the  mirror  image. 

The  normal  anterior  wall  of  the  pharynx  shows  the 
sharply  defined  edge  of  the  nasal  septum  in  the  median 
line.  Prominences  on  either  side  of  the  septum  are 
pathologic.     The  rear  ends  of  the  inferior  and  middle 

6 


66  NASAL   AND    PHARYNGEAL    AFFECTIONS. 

turbinals  are  well  seen  in  the  normal  image.  They 
appear  as  pale,  scarcely  pink,  obliquely  pendant  lobules, 
the  lower  even  paler  than  the  middle,  and  are  covered 
with  a  smooth  mucous  lining.  Normally  there  is  a 
distinct  space  between  the  turbinals  and  the  septum. 
Morbidly  they  may  be  enlarged  to  a  variable  extent,  even 
projecting  into  the  nasopharynx,  and  of  a  bluish,  livid 
hue.  Each  choanal  opening  is  oval,  the  upper  rim  being 
slightly  more  curved  than  the  lower.  Asymmetry  of 
the  two  choanae  is  rare  and  not  normal. 

Prominent  landmarks  on  the  lateral  sides  of  the  upper 
pharynx  are  the  projecting  Eustachian  orifices  posterior 
to  the  inferior  turbinals  and  about  on  their  level.  The 
yellowish-white,  funnel-shaped  orifice  is  surrounded  by 
projecting  lips,  an  anterior  and  a  posterior  one,  which, 
by  diverging  downward,  give  the  opening  the  shape  of  a 
triangle  with  curved  outlines.  The  prominence  of  the 
Eustachian  tube  is  subject  to  variation,  and  in  proportion 
to  its  projection  varies  the  depth  of  the  recess  above  and 
behind  the  Eustacliian  lips — the  Rosenmiiller  fossa. 

When  a  rhinoscopic  view  cannot  be  obtained,  exami- 
nation with  the  finger  can  inform  the  surgeon  regarding 
the  size  of  the  pharyngeal  tonsil,  and  any  existing 
hypertrophy  of  the  inferior  turbinated  or  other  growths. 
A  practical  plan  to  prevent  children  from  biting  during 
the  digital  examination  is  to  press  in  the  cheek  between 
the  molar  teeth  with  the  other  hand. 

25.  Methods  of  Treatment  in  Nasal  and  Pharyn- 
geal Affections. — Applications  in  Nose  and  Pharynx. — 
The  nasal  douche  is  used  for  both  diagnostic  and  therapeu- 
tic purposes.  When  we  wish  to  know  if  there  is  any  se- 
cretion in  the  nose,  in  case  it  cannot  be  seen,  it  will  be 
found  in  the  basin  receiving  the  water  with  which  the 
nose  has  been  flushed.  The  douche  serves  likewise  to 
remove  viscid  secretion  or  crusts  in  order  to  expose  the 
surface  to  view.  For  curative  purposes  the  douche  is 
invaluable  in  all  cases  in  which  the  discharge  cannot  be 
removed  by  other  means—  viz. ,  when  it  is  dried  in  exten- 


TREATMENT    IN    NASAL    AND    PHARYNGEAL   AFFECTIONS.     6/ 

sive  crusts  or  when  it  is  viscid.  The  principle  of  the 
douche  is  simply  to  wash  the  nasal  surfaces  with  a 
current  of  indifferent  fluid.  Pure  water  is  more  irritating 
than  the  so-called  physiologic  salt  solution — i.  e. ,  common 
salt  in  the  strength  of  0.5  to  0.7  per  cent.,  or  the  same 
amount  of  sodium  bicarbonate.  The  douche  should 
never,  however,  be  given  unnecessarily  to  a  patient,  since 
its  careless  use  may  involve  a  grave  danger.  If  the  water 
enters  the  rear  of  the  nose  with  pressure,  or  if  the  patient 
swallows  during  the  time  and  thereby  causes  gaping  of 
the  Eustachian  tubes,  the  water  may  enter  the  middle 
ear.  This  accident  causes,  as  a  rule,  suppurative  inflam- 
mation of  the  middle  ear,  sometimes  of  great  severity. 
It  is  probably  not  the  presence  of  the  water  as  such  in 
the  middle  ear  that  does  the  mischief,  but  the  water  in 
entering  carries  with  it  pathogenic  germs  that  abound  in 
every  diseased  nose. 

In  order  to  guard  against  this  danger  I  have  learned  to 
use  a  pointed  nozzle  that  does  not  occlude  the  nostril,  in 
preference  to  the  olive-shaped  bulb  usually  fitted  to  the 
douche.  I  likewise  find  it  more  convenient  to  use  as 
syringe  a  large  rubber  bulb  held  in  the  hand  rather  than 
the  irrigator  ordinarily  sold  as  a  nasal  douche.  The 
water  should  be  of  the  temperature  of  the  body,  and  the 
patient  must  not  swallow,  cough,  or  spit  while  the 
water  flows.  When  the  patient  leans  forward  with  the 
mouth  open,  the  palate  is  raised  by  reflex  action  while 
the  water  flows  through  the  nose,  so  that  the  fluid  does 
not  get  into  the  lower  pharynx  at  all  or  only  to  a  limited 
extent,  but  returns  through  the  other  side  of  the  nose. 
If  one  side  of  the  nose  is  narrowed,  the  fluid  should 
always  be  made  to  enter  through  the  narrow  side,  in 
order  not  to  be  under  pressure  in  the  upper  pharynx. 

With  these  precautions  I  have  not  had  a  single  accident 
in  many  thousand  applications  made  by  myself  Before 
I  became  familiar  with  all  these  details  I  have  had 
patients  state  a  number  of  times  that  they  felt  the  water 
entering    one    or   both   ears.       In    every   one    of    these 


68  NASAL    AND    PHARYNGEAL    AFFECTIONS. 

instances  I.  inflated  the  middle  ear  immediately  by  the 
Politzer  method  or  with  the  catheter,  and  in  no  case 
were  there  any  further  consequences.  The  use  of  the 
douche  in  the  hands  of  the  patient  is  necessarily  more 
likely  to  lead  to  this  accident  than  when  done  under  the 
eyes  of  the  surgeon.  Hence  the  douche  should  never  be 
ordered  except  when  actually  required.  The  various 
cup-  or  spoon-shaped  vessels  sold  as  nasal  douches  involve 
all  the  dangers  of  nasal  irrigation  without  its  real  utility, 
since  their  contents  do  not  reach  the  upper  portions  of 
the  nasal  chamber. 

When  we  wish  to  cleanse  the  nasopharynx  more  than 
the  nose,  the  postnasal  douche,  a  long  tube  with  curved 
beak  connected  with  the  douche-syringe,  is  inserted 
into  the  nasopharynx  through  the  mouth,  and  the  fluid  is 
allowed  to  run  off"  through  the  nose.  The  same  precau- 
tions are  required  as  with  the  ordinary  form  of  nasal 
douche. 

The  object  of  the  douche — viz. ,  the  removing  of  viscid 
adhering  secretion  or  crusts — cannot  be  attained  by  snuff"- 
ing  up  fluids  or  by  pouring  them  into  the  nose  with  a 
spoon  or  spoon-shaped  vessel.  A  forcible  jet  is  required 
for  the  purpose.  Hence  atomizers,  too,  are  but  an  im- 
perfect substitute  for  the  douche.  But  as  their  use 
involves  no  danger  to  the  ear,  we  must  often  be  contented 
with  some  form  of  spray-producing  apparatus  in  the 
hands  of  the  patient,  especially  in  the  case  of  unruly 
children.  A  copious  spray,  followed  by  repeated  blow- 
ing of  the  nose,  will  remove  fluid  secretion  fairly  well, 
but  not  adherent  crusts.  Considerable  air-pressure  is 
necessary  to  produce  a  good  spray.  A  single  rubber  bulb 
is  preferable  to  a  double  bulb.  For  office  use  a  tank  for 
compressed  air  is  a  great  convenience,  though  not  an 
absolute  necessity.  About  20  pounds'  pressure  answers 
all  demands.  When  the  spray  is  used  for  cleansing  pur- 
poses, a  I  per  cent,  solution  of  sodium  bicarbonate  is  all 
that  is  required. 

Antiseptics  of  a  sufficient  strength  for  actual  disinfection 


TREATMENT    IN    NASAL   AND    PHARVNGEAL    AFFECTIONS.     69 

are  not  tolerated  by  the  mucous  membrane.  Besides,  it 
has  been  shown  by  numerous  experiments  that  mucous 
membranes  cannot  be  sterilized  in  the  same  manner  as  the 
skin.  The  only  substances  suitable  for  sprays  to  which 
a  distinct  influence  and  perhaps  a  slight  antiseptic  effect 
can  be  ascribed  in  the  treatment  of  nasal  diseases  are  the 
essential  oils  dissolved  in  water.  These  solutions  are  not 
irritating ;  if  anything,  they  are  agreeable  and  clinically 
superior  in  their  therapeutic  effect  to  indifferent  fluids. 
After  many  trials  the  author  has  found  the  following 
preparation  the  most  agreeable :  Oil  of  cloves,  2  per 
cent.  ;  oil  of  wintergreen,  0.5  per  cent.  ;  menthol,  0.5 
per  cent.,  are  triturated  with  magnesia,  and  the  necessary 
quantity  of  water,  with  the  addition  of  i  per  cent,  of 
sodium  bicarbonate,  is  added  and  the  mixture  filtered. 
Only  a  part,  however,  of  the  essential  oils  really  enters 
into  solution.  A  favorite  solution  with  many  for  nasal 
use  is  Seller's  antiseptic  solution,  which  contains: 

Sodium  bicarbonate 240  grains 

Borax 240      " 

Sodium  benzoate 10      " 

Sodium  salicylate 10      " 

Eucalyptol 5  minims 

Thymol 5  grains 

Menthol 2_J^  grains 

Oil  of  wintergreen 3  drops 

Glycerin 4  ounces 

Alcohol ' I  ounce 

Water  to  make  8  pints. 

The  ingredients  are  also  put  up  in  tablets,  of  which  one 
is  intended  for  a  two-ounce  solution.  For  nasal  use 
Dobell's  solution,  quoted  extensively  in  text-books,  con- 
sists of : 

Borax i  dram 

Glycerinated  carbolic  acid  (20  per  cent.)    ...  2  drams 

Sodium  bicarbonate i  dram 

Tepid  water ^  pint. 

Neither   of   these   solutions  can  be  said  to  possess  any 


fO  NASAL   AND    PHARYNGEAL   AFFECTIONS. 

therapeutic  influence  beyond  the  mechanical  eflfect  they 
exert  as  spray  or  wash. 

An  antiseptic  fluid  of  great  penetrating  power  and  in- 
tense germicidal  action  (within  a  few  seconds)  is  Loffier's 
solution,  much  used  in  diphtheritic  and  other  infectious 
forms  of  pharyngitis.     Its  formula  is — 

Menthol lO 

Toluene 36 

Creolin 2 

Tincture  of  iron  chlorid 4 

Alcohol up  to  100. 

To  be  applied  undiluted  and  kept  in  contact  for  at  least 
ten  seconds  (see  1  203). 

Oily  solutions  made  with  liquid  petroleum  or  the  hydro- 
carbons, known  as  albolene,  etc.,  can  be  difiused  well  in 
the  form  of  fine  sprays  by  the  class  of  atomizers  known 
as  vaporizers.  The  author,  by  unprofitable  experience, 
has  become  fully  satisfied,  however,  that  there  is  no 
permanent  benefit  of  any  kind  to  be  obtained  from  oily 
solutions.  Even  the  striking  influence  of  menthol  solu- 
tions in  vaselin  is  but  transient,  and  gives  no  satisfactory 
result  in  the  end. 

Fluids  are  best  applied  to  small  areas  of  the  nasal  sur- 
face on  pledgets  of  cotton  wound  around  wooden  tooth- 


FiG.  20. — Pharyngeal  applicator. 

picks.  Applications  to  the  pharynx  require  the  use  of 
long  wire  applicators,  the  end  of  which  is  bent  at  a  right 
angle  (Fig.  20).  Cotton  is  wrapped  around  the  screw- 
thread  at  the  end.  Brushes  and  sponges  should  never  be 
successively  used  on  more  than  one  patient. 


ACTION    OF    DRUGS. 


71 


Powders  are  blown  into  the  nose  and  pharynx  by  means 
of  insufflators  (Fig.  24).  Such  instruments,  with  a  re- 
ceiver for  holding  a  store  of  the  powder,  have  been 
devised  by  the  author,  De  Vilbiss,  and  others.  Curved 
tube  attachments  permit  the  blast  to  be  directed  upward 
in  the  pharynx.  An  additional  tubular  nozzle  facilitates 
asepsis  of  the  end  of  the  instrument. 

The  lower  pharynx  is  commonly  supposed  to  be  reached 
by  gargling.  This  is  not  entirely  true.  During  gargling 
contact  between  the  root  of  the  tongue  and  the  soft  pal- 


FlG.  21. — Author's  powder-blower. 


ate  separates  the  mouth  from  the  pharynx  proper,  and 
drops  of  the  solution  pass  this  barrier  only  by  accident. 
This  has  been  shown  by  using  staining  solutions.  Hence 
since  the  gargling  fluid  reaches  the  rear  pharyngeal  wall 
but  very  imperfectly,  this  mode  of  application  is  less 
efficient  than  that  of  brushing  or  sprays. 

26.  Action  of  Drugs  upon  the  Respiratory  Mucous  Mem- 
brane.— Cocain  constricts  the  blood-vessels  of  the  surface 
to  which  it  is  applied,  and  thus  shows  the  difference  be- 
tween their  distended  and  contracted  condition.  Its 
effect,  hence,  permits  a  better  view  of  the  interior  of  the 
nose.  It  gives  a  subjective  feeling  of  clearing  of  the 
nose,  which  is  more  marked  the  greater  the  previous 
obstruction  caused  by  vascular  distention.  A  2  per  cent, 
solution  does  this  fairly  well  unless  the  mucous  mem- 
brane is  inflamed,  when  a  strength  of  about  i  :  20  is 
required.     A  spray  of  this  strength  is  harmless  if  used 


J 2  NASAL   AND    PHARYNGEAL    AFFECTIONS. 

sparingly.  For  anesthesia  a  solution  of  at  least  5  per 
cent,  strength  is  necessar\'.  If  deep  action  is  desired,  20 
per  cent,  and  from  five  to  ten  minutes'  contact  are  re- 
quired. The  anesthesia  lasts  from  ten  to  twenty  minutes. 
The  author  has  made  use  of  this  strength  of  cocain  solu- 
tion on  pledgets  of  cotton  tightly  wrapped  around  tooth- 
picks in  thousands  of  instances,  and  has  never  seen  any 
alarming  effects  produced.  It  is  not  an  uncommon  occur- 
rence, however,  for  the  patient  to  complain  of  subjective 
faintness  or  "nervousness,"  due  partly  to  the  cocain  and 
partly  to  the  dread  of  operations,  and  it  is  well  to  be  pre- 
pared to  have  the  patients  lie  down  for  a  few  minutes. 
When,  formerly,  the  author  used  cocain  on  loose  pledgets 
of  cotton,  he  saw  these  accidents  more  frequently  and 
twice  was  embarrassed  by  acute  maniacal  attacks  lasting 
a  few  hours.  In  children  I  have  occasionally  observed 
embarrassing  talkativeness  after  the  pharyngeal  use  of 
cocain.  Since  more  serious  accidents  have  been  recorded 
by  others,  care  should  be  used  in  the  employment  of 
cocain  to  avoid  any  dripping  of  the  solution  into  the 
lower  part  of  the  throat. 

A  deep  localized  anesthesia  can  be  obtained  by  the 
submucous  injection  of  weak  solutions  of  cocain  (0.5  to 
I  per  cent.)  or  eucain  (0.2  percent,  in  indifferent  salt 
solution  (0.6  per  cent.)  according  to  the  Schleich  method 
of  infiltration.  This  is  especially  applicable  in  operations 
on  the  septum.  An  ordinary  hypodermic  syringe  with 
long  needle  is  required. 

An  excellent  substitute  for  cocain  for  the  purpose  of 
local  anesthesia  is  nirvanin.  It  has  been  found  harmless 
and  not  productive  of  poisonous  effects,  but  it  acts  only 
when  injected  into  the  tissues,  and  not  on  the  free  sur- 
face. It  may  be  used  in  from  3  to  5  per  cent,  solution  in 
water. 

In  order  to  anesthetize  the  phar^'nx  the  applicator, 
moistened,  but  not  dripping,  with  cocain  solution  (20 
per  cent.),  must  be  held  in  place  for  a  few  minutes.  The 
pharyngeal   anesthesia    is   neither   complete    nor   deep. 


ACTION    OF    DRUGS.  73 

Cocain  anesthesia  in  the  nose  or  pharynx  is  very  much 
intensified  by  the  anemia  caused  by  a  prior  employment 
of  suprarenal  extract.  Under  no  circumstances  should 
cocain  be  given  into  the  hands  of  patients,  for  fear  of 
inducing  the  pernicious  cocain  habit.  The  relief  this 
drug  gives  in  turgescence  of  the  nasal  lining  is  a  great 
temptation  to  its  continued  use.  In  cases  of  known 
idiosyncrasy  against  cocain  eucain  /9  may  be  used  in  its 
stead  in  5  per  cent,  solution  for  purposes  of  anesthesia, 
but  otherwise  it  has  no  advantage  over  cocain.  Eucain 
does  not  constrict  the  blood-vessels. 

Orbhofonn  has  no  influence  upon  intact  mucous  surfaces, 
but  its  remarkable  anesthetic  effect  upon  exposed  tissues 
can  be  utilized  advantageously  by  blowing  the  powder 
upon  painful  wounds — for  instance,  after  tonsillotomy. 
Intranasal  wounds  do  not  ordinarily  require  it. 

A  solution  of  the  active  principle  of  the  suprarenal 
gland  produces  an  intense  anemia  upon  local  application, 
which  continues  for  one  or  two  hours.  On  inflamed  sur- 
faces its  effect  is  more  difficult  to  obtain  and  more  tran- 
sient. Its  use  renders  nasal  operation  almost  bloodless. 
Its  previous  application  intensifies  cocain  anesthesia.  A 
5  to  10  per  cent,  solution  suffices.  The  solution  filters 
very  slowly,  and  hence  may  be  prepared  by  allowing  the 
dried  powder  from  which  it  is  made  to  settle  by  deposi- 
tion. It  putrefies  speedily  unless  preserved  sterile*.  It  is 
not  altered  by  boiling,  but  the  sterility  is  lost  on  opening 
the  flask.  The  addition  of  i  per  cent,  chloroform  (more 
than  enough  to  saturate  water)  preserves  it  permanently. 
The  chloroform  is  only  very  slightly  irritant,  and  may, 
besides,  be  driven  off"  by  heating.  Chloroform  is  also  a 
useful  agent  for  the  preservation  of  sterility  of  other  solu- 
tions, kept  in  bottles  repeatedly  opened — for  instance, 
cocain.  As  a  spray  for  the  temporary  reduction  of  intra- 
nasal turgescence  a  solution  of  cocain  (2  per  cent.)  and 
suprarenal  extract  (2  per  cent.)  is  very  appropriate  in  the 
hands  of  the  surgeon.  In  rare  instances,  however,  supra- 
renal solution  causes  disagreeable  sneezing  fits^coryza 


74  NASAL   AND    PHARYNGEAL    AFFECTIONS. 

vasomotoria.  Suprarenal  solution  loses  its  activity  grad- 
ually. In  order  to  be  reliable  it  should  have  been  pre- 
pared within  less  than  one  week. 

Menthol,  too,  produces  constriction  of  the  venous  plexus 
in  the  mucous  membrane,  but  less  than  cocain.  The 
subjective  feeling  of  clearness  due  to  the  reduced  turges- 
cence  is  intensified  by  the  cooling  sensation  caused  by 
menthol,  but  it  does  not  anesthetize  the  surface.  A  fine 
spray  of  menthol  dissolved  in  six  parts  of  fluid  vaselin  or 
albolene  gives  a  pleasant  relief  whenever  the  nasal  pas- 
sage feels  "stuffy,"  but  the  effect  is  transient  in  propor- 
tion to  the  inflammatory  condition  causing  the  vascu- 
larity. Coarse  sprays  or  menthol  solution  applied  directly 
are  irritating. 

27.  Surgical  Procedures  in  the  Nose  and  Pharynx — In 
order  to  avoid  repetition  it  may  be  convenient  to  describe 
certain  surgical  measures  which  are  employed  in  various 
morbid  conditions. 

Cauterization. — Superficial  cauterizations  can  be  made 
with  a  bead  of  silver  nitrate  melted  on  a  probe  without 
unpleasant  reaction.  A  deeper  caustic  effect  is  obtained 
by  chromic  acid  handled  in  the  same  way.  The  excess 
should  be  washed  away  with  sodium  bicarbonate  solution. 
Chromic  acid  burns  are  often  slow  in  healing.  This  dis- 
advantage does  not  apply  to  cauterization  with  trichlor- 
acetic acid,  which  causes  less  inflammatory  reaction 
than  the  former,  while  ver>'  voluminous  eschars  indicate 
its  penetrating  power.  Its  hygroscopic  nature  renders 
it  awkward  to  manage.  Only  fresh  dry  crystals  can  be . 
melted  on  a  probe,  and  this  with  difficulty.  The  crystals 
can  be  held  in  cup-shaped  applicators,  or  when  melted 
may  be  absorbed  by  cotton  wound  around  a  probe.  The 
application  of  the  acid  should  be  followed  at  once  by  an 
alkaline  wash.  The  slough  produced  by  chemical  or 
actual  cauterization  becomes  detached  within  from  four 
to  seven  days,  according  to  its  depth.  The  wound  then 
heals  in  from  six  to  fifteen  days  and  requires  no  treatment 
except  occasional  removal  of  crusts. 


SURGICAL    PROCEDURES    IN    THE    NOSE    AND    PHARYNX.       75 

The  deepest  and  most  localized  caustic  effect  is  obtained 
by  means  of  galvanocaustic  burners  shaped  according  to 
the  locality  and  object  they  are  intended  for  (Figs.  22 
and  23).     The  handle  of  the  cautery  must  have  a  push- 


iC 


iiiiiiiiiiiimii ■■■ ■Mil! iMiiiMiiiiiiiiiiiiiii eC^ 


Fig.  22. — Galvanocaustic  burners. 


isC 


button  in  order  to  regulate  the  duration  of  the  current. 
By  far  the  most  convenient  source  of  electricity  is  a  con- 
verter attached  to  a  low  tension,  alternating  street  current, 
when  accessible,  as  this  requires  no  care.     When  only  a 


Fig.  23. — Handle  for  galvanocaustic  electrodes. 

''constant"  street  current  is  available,  the  problem  of 
getting  a  current  of  low  voltage  (from  6  to  10  volts)  and 
of  sufficient  intensity  (20  to  25  amperes)  is  more  compli- 
cated. The  large  rheostats  supplied  by  makers  cannot  be 
recommended.  They  are  expensive,  absorb  very  much 
current,  and  still  give  too  high  a  voltage,  which,  in  case 
of  a  "leak,"  may  prove  at  least  very  unpleasant,  if  not 
dangerous.  It  is  preferable  to  interrupt  the  current  by  a 
motor  and  then  to  reduce  the  voltage  by  a  converter,  as 
sold  by  the  Edison  and  other  companies.  A  "motor 
converter"  may  be  used,  which,  by  double  winding  of 
the  armature,  gives  a  suitable  current  of  low  voltage.  An 
excellent  one  made  by  the  Victor  Electric  Co.,  of  Chicago, 
has  been  used  by  the  author  for  several  years  with  satis- 
faction (Fig.  24).  The  motor  itself,  when  connected 
with  a  "dental    arm,"  is  a  very  convenient  source  of 


1^ 


NASAL    AND    PHARYNGEAL    AFFECTIONS. 


power  for  operations  with  drill  or  trephine.  A  storage 
battery  of  two,  or,  better  still,  three,  cells  of  good  make 
and  well  charged  in  the  first  place  is  the  next  best  source 
of  electricity.  It  must  be  kept  charged  by  connection 
with  a  lighting  current  at  intervals  of  some  weeks.  If 
allowed  to  remain  inactive  too  long,  "it  runs  down" 
by  means  of  internal  chemical  changes  and  then  re- 
quires a  charging  current  of  several  amperes  in  order  to 
be  restored.     Constant   batteries   generally   require    fre- 


FiG.    24. — Victor  motor   transformer  for  cautery  with    attachment    for  dental 
cable  for  operating  drills,  etc.,  also  an  attachment  for  pump  for  ear  massage. 

quent  attention  and  refilling  in  order  to  keep  in  good 
condition.  The  directions  are  supplied  by  the  manu- 
facturer. Perhaps  the  most  desirable  of  all  available 
cells  is  the  Edison  Lacland  type,  largest  pattern,  of  which 
three  in  series,  or  six  in  two  series  of  three,  are  necessary. 
Since  both  constant  batteries  and  storage-cells  lose 
slightly  in  the  course  of  time,  it  is  best  to  have  an  excess 
of  power  in  the  first  place.  A  small  rheostat  or  the  re- 
sistance of  a  variable  length  of  thick  German-silver  wire 


SURGICAL    PROCEDURES    IN    THE    NOSE    AND    PHARYNX.       // 


regulates  the  strength  of  current.  With  a  voltage  of  at 
least  six  volts  the  cords  used  commercially  for  electric 
drop-lights  (largest  size)  are  available  in  preference  to  the 
stiffer  cords  generally  sold  by  the  surgical  supply  houses. 

The  object  of  cauterization  is  to  re- 
move redundant  tissue.  If  this  can  be 
done  with  scissors  or  snare,  a  clean  and 
rapidly  healing  wound  is  left,  which 
is  much  preferable  to  the  slow  heal- 
ing and  discomfort  of  a  burnt  wound. 
But  cutting  instruments  are  not  al- 
ways applicable,  especially  in  the  case 
of  flat  tumefactions  or  enlargement  of 
the  submucous  venous  plexus.  The 
heated  burner  acts  beyond  the  area  of 
the  eschar  which  it  produces,  causing 
thrombosis  in  the  adjacent  vessels,  with 
considerable  ultimate  obliteration.  It 
is  an  advantage  to  destroy  as  little  as 
possible  of  the  mucous  surface,  which 
can  be  done  by  making  multiple  deep 
punctures  instead  of  extensive  surface 
burns.  The  larger  the  surface  that  has 
been  destroyed,  the  slower  the  healing 
and  the  greater  the  probability  of  sec- 
ondary infection  during  healing.  Be- 
sides, the  resulting  scar  is  liable  to 
be  covered  with  crusts  for  long  periods 
of  time.  Attempts  have  been  made  at 
submucous  cauterization  with  needle- 
shaped  burners,  but  the  results  do 
not  differ  materially  from  multiple 
punctures.  R 

28.  An  instrument  much  used  for  Fig.  2s.-jarvis' snare. 
nasal  work  is  the  snare  (Figs.   25,   26,   27).     The  most 
convenient  form  is  that  in  which  the  wire  is  threaded 
through  an  eye  in  a  stilet,  like  Wright's  and  Krause's. 
Otherwise   much    time   is   wasted    in   pulling   the    wire 


78 


NASAL    AND    PHARYNGEAL    AFFECTIONS. 


through   the   cannula.     Steel   piano   wire  is   used,    but 
should  not  be  bought  on  spools,  as  such  winding  curls 


Fig.  26. — Wright's  snare. 

it   too   much.     The   snare   loop    is   slipped  around    the 
utmost  base  of  the  growth  to  be  removed.      When  the 


Fig.  27. — Krause's  nasal  snare  (with  stilet). 

growth  is  flat  and  does  not  project,  it  can  be  transfixed 
with  a  needle  (Fig.   28),  over  which  the  loop  of  wire  is 


Fig.  28. — Jarvis'  transfixion  needle. 


slipped.     Where   hemorrhage   is   feared    on    account  of 
vascularity,    the   cutting    should   be   done   very   slowly 


HEMORRHAGE    FROM    THE    NOSE.  79 

(preferably  with  a  Jarvis  snare,  the  nut  of  which  is 
turned  gradually). 

The  hot  snare  (Fig.  29),  an  attachment  to  the  galvano- 
cautery  handle,  has  little  advantage  over  the  cold  snare. 
The  difference  in  the  amount  of  bleeding  is,  as  a  rule, 
only  slight,  whereas  the  inconvenience  of  the  hot  snare 
to  the  surgeon  is  considerable.  The  same  steel  wire  may 
be  used  as  in  the  cold  snare,  but  must  be  replaced  each 
time.  Platinum  wire  is  not  much  better  and  very  ex- 
pensive. 

29.  Hemorrhage  from  the  nose  or  that  following  opera- 
tions in  the  pharynx  will  generally  cease  spontaneously 
if  not  of  arterial  origin.     The  patient  should  keep  quiet 


Fig.  29. — Galvanocaustic  snare-handle  (Kuttner's). 

and  reduce  the  blood  pressure  in  the  head  by  standing 
upright  or  at  least  sitting.  Tannin  and  other  astringents 
blown  into  the  nose  or  pharynx  do  not  stop  bleeding. 
A  more  definite  effect  on  hemorrhage  can  be  obtained 
by  the  use  of  coarse  glutol  powder,  which  probably 
acts  mechanically.  If  the  nasal  bleeding  is  arterial — 
if  it  spurts  and  is  bright  red — or  even  if  venous,  and 
does  not  cease  soon  or  is  very  copious,  the  nose  must  be 
plugged.  A  strip  of  iodoform  gauze  i  to  2  cm.  wide  and 
about  J  m.  in  length  is  packed  in  with  the  probe. 
Cotton  will  answer  equally  well  for  the  time,  but  in  the 
case  of  wounds  does  not  help  to  keep  them  aseptic.  It 
is  handy  to  wind  the  cotton  in  required  thickness  upon 
tooth-picks,  using  a  sterile  cloth  over  the  fingers  in  order 


80  NASAL    AND    PHARYNGEAL    AFFECTIONS. 

not  to  infect  the  cotton.  If  the  hemorrhage  is  from  the 
rear  end  of  the  turbinal  or  from  the  pharyngeal  vault, 
the  upper  pharynx  must  be  packed.  A  plug  of  iodoform 
gauze  or  iodoform  cotton  with  a  string  attached  can  be 
pushed  up  behind  the  palate  through  the  pharynx  by 
means  of  curved  forceps,  if  necessary  with  the  aid  of  a 
palate  retractor.  This  is  difficult  on  account  of  the 
patient's  gagging.  A  neater  way  is  by  means  of  a 
Belloc's  sound  (Fig.  30).  The  slightly  curved  tube  is 
passed  through  one  nostril.  A  springy  stilet,  when 
pushed  through  this  tube,  curves  down  behind  the  soft 
palate,  and  the  cord  attached  to  a  gauze  plug  can  then  be 
threaded  through  the  eye  of  the  stilet  in  the  mouth. 
Upon  withdrawal  of  the  Belloc  sound  this  cord  can  now 
be  pulled  at  its  emergence  from  the  nostril,  and  the  plug 


Fig.  30. —Belloc's  sound  for  plugging  the  postnasal  space. 

thus  be  lifted  into  place.  A  second  string  attached  to 
the  plug  hangs  out  of  the  mouth  and  is  tied  over  the 
upper  lip  to  its  mate  in  the  nose. 

Packing  does  not  stop  the  visible  hemorrhage  instantly  : 
it  usually  requires  a  few  minutes'  waiting.  If  the 
hemorrhage  persists  to  an  alarming  extent  after  packing, 
cotton  plugs  moistened  with  iron  persulphate  will  control 
it.  On  account  of  the  irritation  that  they  produce,  how- 
ever, they  should  never  be  used  except  in  case  of  positive 
danger.  Less  disagreeable  than  the  iron  solution  and 
nearly  as  effective  is  the  combination  of  antipyrin  and 
tannin,  which  forms  a  sticky  paste.  The  cotton  plug  or 
pledget  is  brushed  with  antipyrin  solution  (10  per  cent.), 
then  dusted  freely  with  tannin  powder.  In  persons 
known  to  be  bleeders  it  is  best  to  avoid  nasal  operations, 


HEMORRHAGE    FROM    THE    NOSE.  iSl 

if  possible.  In  such  subjects  even  the  galvanocaustic 
burner  may  lead  to  embarrassing  secondary  hemorrhage. 
Several  personal  experiences,  however,  with  bleeders 
terminated  well  ultimately. 

30.  At  the  present  time  every  surgeon  recognizes  that 
it  is  his  duty  to  have  every  instrument  sterilized  before  it 
is  brought  into  contact  with  a  wound  or  an  absorbing  sur- 


FiG.  31. — Author's  sterilizer  with  removable  bottom  (B)  and  cover  (C). 
a  steam  chamber  for  steam  disinfection. 


Dis 


face.  The  only  method  that  gives  absolute  assurance  of 
complete  disinfection  is  three  minutes'  boiling  in  i  per 
cent,  sodium  carbonate  solution.  In  the  absence  of  spores, 
even  one  minute  suffices  to  kill  germs.  On  account  of 
the  solvent  action  of  hot  soda  solution  upon  dirt  this  ren- 
ders unnecessary  the  painstaking  scrubbing  which  must 
precede  immersion  in  cold  antiseptic  solutions  (5  per 
6 


S2  NASAL    AND    PHARYNGEAL   AFFECTIONS. 

cent,  carbolic  acid  or  o.  i  per  cent,  corrosive  sublimate). 
It  is  advisable  to  have  a  sterilizing  kettle  (Fig.  31)  in 
permanent  use  next  to  the  instrument  table,  and  to  get 
into  the  habit  of  throwing  all  instruments  into  it  after 
use.  For  instruments  used  merely  for  examination  and 
not  coming  into  contact  with  wounds, — for  instance,  the 
rhinoscopic  mirror  and  the  nasal  speculum, — scrubbing 
with  a  brush  under  running  water  suffices,  whereas  the 
mere  dipping  into  a  disinfecting  solution  is  useless, 
because  inefficient.  When  there  is  any  suspicion,  how- 
ever, of  contagious  disease,  syphilis,  tuberculosis,  diph- 
theria, or  even  acute  angina,  it  is  our  duty  to  boil  the 
instruments  after  use,  even  if  the  rhinoscopic  mirror  does 
deteriorate  gradually.  The  nozzles  of  rubber  throat- 
atomizers  withstand  boiling  without  damage.  Cotton 
swabs  wound  on  tooth-picks  for  mopping  and  for  applica- 
tions can  be  kept  aseptic  by  handling  the  cotton  with  a 
sterile  cloth  instead  of  with  the  naked  fingers. 

It  has  been  claimed  by  St.  Clair  Thompson  and  Hew- 
lett that  the  normal  nasal  lining  is  generally  free  from 
bacteria,  and  that  they  are  largely  deposited  in  the  vesti- 
bule or  expelled  from  the  mucous  surface  by  the  move- 
ments of  the  epithelial  cilia.  As  all  other  mucous  mem- 
branes are  likely  to  have  germs  upon  their  surfaces,  this 
statement  ought  not  to  be  accepted  fully  until  it  is 
extensively  corroborated.  The  impossibility  of  practi- 
cally sterilizing  other  even  more  accessible  mucous  mem- 
branes, like  those  of  the  conjunctiva  or  vagina,  excludes 
all  hope  of  successfully  sterilizing  the  surfaces  of  nose  or 
pharynx  by  present  methods.  Since  the  nasal  mucous 
membrane  cannot  be  made  sterile,  we  cannot  guarantee 
an  aseptic  course  after  operations.  Attempts  to  keep  the 
surfaces  protected  against  germs  by  means  of  painting 
with  methyl-violet  and  other  antiseptic  substances  have 
not  proved  successful  and  do  not  seem  rational  to  the 
bacteriologist.  The  only  real  protection  is  afforded  by 
iodoform  gauze  packed  closely  against  a  wound,  since 
iodoform  in  powder  form  is  soon  swept  away  "by  secretion. 


HISTORY   AND    LITERATURE.  83 

Clinical  experience  has  led  me  to  trust,  to  some  extent, 
to  glutol  in  coarse  powder  blown  upon  the  thoroughly 
clean  and  dry  wound.  This  substance,  by  reason  of  its 
absorbing  power,  helps  to  stop  bleeding  and  forms  a  well- 
adhering  crust  under  which  wounds  in  the  nose  and 
throat  have  healed  in  a  very  clean  and  rapid  manner. 
Fortunately,  however,  wounds  in  the  nose  and  throat  do 
not  often  follow  an  untoward  course.  Superficial  infec- 
tion is  almost  inevitable  except  under  iodoform  gauze  or 
under  a  glutol  scab,  but  suppuration  of  wounds  is  not 
common  in  the  nose,  although  more  so  in  the  pharynx. 
Traumatic  erysipelas  is  very  rare.  Pyogenic  infection 
of  nasal  wounds  sometimes  leads  to  acute  tonsillitis — on 
the  same  side  and  perhaps  later  on  the  other  side — or  to 
suppurative  inflammation  of  the  middle  ear  or  of  the 
maxillary  sinus.  Streptococcus  infection  may  manifest 
itself  by  the  prolonged  formation  of  false  membranes 
with  delayed  healing,  but  usually  without  serious 
danger. 

History  and  Literature.— The  former  scanty  knowledge  con- 
cerning .surgical  diseases  of  the  nose  and  pharynx  (polypi,  ma- 
lignant tumors,  empyema  of  frontal  and  maxillary  sinus,  and 
tonsillar  enlargement)  can  be  found  in  the  text-books  on  surgery 
of  the  various  times.  From  a  medical  point  of  view,  these  parts 
received  no  attention  worth  mentioning  prior  to  the  introduction 
of  the  laryngoscope  by  Tiirck  and  Czermak  (1858),  except  in  the 
case  of  acute  infections  of  the  pharynx.  In  1859  Czermak  applied 
the  inverted  laryngoscopic  mirror  to  the  postnasal  space.  Ante- 
rior nasal  inspection  through  a  speculum  was  employed  by  Mar- 
kusovszki,  of  Pesth,  in  1859,  but  popularized  by  Thudichum 
(Duplay,  and  especially  B.  Frankel)  only  after  1868.  Thudichum 
also  introduced  into  therapeutics  the  nasal  douche  (1864)  pre- 
viously used  for  physiologic  purposes  by  Weber.  The  danger 
of  the  douche  to  the  ear  was  later  shown  by  Roosa.  While  the 
knowledge  of  the  various  affections  of  the  nose  was  gradually 
augmented  by  laryngologists  of  all  countries,  the  most  important 
discovery  regarding  postnasal  pathology  was  the  description 
of  the  enlarged  pharyngeal  tonsil  (adenoid  vegetations)  by  W. 
Meyer,  whose  first  report  in  Danish  literature  in  1868  was  supple- 
mented by  his  more  accessible  German  publication  in  1873. 
Medical  interest  in  the  nose  as  a  source  of  wide-spread  nervous 


84  NASAL   AND    PHARYNGEAL   AFFECTIONS. 

"reflexes"  (asthma,  headache,  etc.)  was  aroused  by  Hack's  an- 
nouncements in  i88i,  continued  for  several  years.  The  important 
role  played  by  the  accessorj^  cavities  in  suppuration  hitherto  con- 
sidered of  intranasal  origin  was  emphasized  by  Ziem  in  1881,  and 
has  received  extensive  attention  within  the  last  twelve  years. 

Rhinologic  study  should  begin  with  the  fundamental  treatise 
by  Zuckerkandl  on  the  anatomy  of  the  nose  (magnificentU'  illus- 
trated), Normale  und  pathologische  Anatomie  der  Nasenhbhle,  Bd. 
i.,  1882,  and  2.  Ed.,  1893,  Bd.  ii.,  1892.  Nasal  pathology  is  illus- 
trated by  Seifert  and  Kahn's  Atlas  der  Histopathologic  der  Nase, 
Mundrachenhohle,  und  des  Kehlkopfs,  1895.  Among  general 
treatises  on  nose  and  pharynx  B.  Frankel's  volume  in  Ziemssen's 
Ha7idbuch  d.  spec.  Pathologic  (1876)  was  the  earliest  in  date,  while 
among  the  most  comprehensive  recent  text-books  may  be  men- 
tioned Burnett's  System  of  Diseases  of  the  Ear,  Nose,  and  Throat, 
1893,  and  especially  the  Hayidbuch  der  Laryngologie  und  Rhinol- 
ogic, begun  in  1896  under  the  editorship  of  P.  Heyman.  Among 
the  landmarks  on  this  subject  may  be  mentioned  the  Diseases  of 
the  Throat  and  Nasal  Passage  hy  "i.  Solis  Cohen,  2  Ed.,  1879,  ^^^ 
The  Diseases  of  Nose  and  Throat,  by  Morell  Mackenzie,  vol.  i., 
1880,  and  vol.  ii.,  1884.  Much  historic  information  can  be  found 
in  this  work  and  in  J.  N.  Mackenzie's  articles  on  "Nasal  Aifec- 
tions  "  in  Wood's  Reference  Handbook  of  the  Medical  Sciences, 
vol.  viii. 


CHAPTER   IV. 

DISEASES  OF  THE   VESTIBULE  OF  THE    NOSE. 
CORYZA. 

DISEASES  OF  THE  VESTIBULE. 

31.  The  entrance  into  the  nose  is  not  often  the  prim- 
ary seat  of  disease,  but  suffers  frequently  in  the  course  of 
various  intranasal  affections,  especially  purulent  rhinitis. 

Bc^ema  occurs  sometimes  in  the  acute,  more  often  in 
the  chronic,  form.  The  characteristic  vesicles  are  soon 
transformed  into  moist  scabs  covering  an  excoriated, 
bleeding  surface.  The  patch  extends  usually  downward 
over  the  upper  lip,  but  is  sometimes  limited  to  the  floor 
and  sides  of  the  vestibule.  Eczema  is  most  commonly 
seen  in  scrofulous  children.  Sometimes  it  is  also  a  per- 
sistent annoyance  in  adults  with  morbid  nasal  secretion. 
When  of  long  duration,  it  is  likely  to  cause  thickening 
of  the  upper  lip,  typically  seen  in  scrofulous  children. 
The  eczematous  abrasion  may  permit  the  entrance  of  the 
tubercle  bacillus  into  the  lymphatic  system,  as  indicated 
by  permanent  enlargement  of  the  anterior  cervical  lymph- 
glands.  It  may  likewise  prove  the  starting-point  of 
facial  erysipelas.  The  eczematous  crusts  should  be  re- 
moved, and  the  surface  protected  by  a  zinc  oxid  lanolin 
salve  (50  per  cent.).  Rebellious  cases  are  cured  in  the 
quickest  manner  by  cauterization  with  silver  nitrate, 
repeated  if  necessary.  Oil  of  cade  salve  (i  :  4)  and 
balsam  of  Peru  act  more  slowly,  but  are  especially  useful 
in  preventing  relapses. 

An  annoying  and  easily  overlooked  lesion  is  a  shallow 
fissure  at  the  junction  of  the  septum  and  the  lateral  wall 
of  the  external  nose.  It  is  more  or  less  painful,  always 
tedious  in  its  course,  and  likely  to  recur  if  partially 
healed.     Sometimes  it  maintains  an  embarrassing  red- 

85 


86  DISEASES    OF   THE    VESTIBULE    OF    THE    NOSE. 

ness  of  the  tip  of  the  nose.  Occasionally  it  is  the  start- 
ing-point of  spells  of  sneezing.  Its  presence  favors  acute 
"  colds."  A  fissure  causes  pain  when  the  nasal  speculum 
is  inserted.  It  can  be  seen  on  searching  for  it.  It  yields 
most  readily  to  repeated  applications  of  silver  nitrate 
solution  (30  per  cent.)  on  thin  cotton  applicators. 

Furuncles  of  the  hair-follicles  in  the  vestibule  give 
rise  to  decided  pain  and  swelling  and  sometimes  to  exter- 
nal redness.  A  furuncle  can  be  recognized  as  a  small 
papular  swelling  on  the  inner  surface  of  the  side  of  the 
nose.  It  should  be  incised  if  it  has  not  broken  sponta- 
neously. Relapses  are  common.  The  best  prevention 
in  my  experience  is  to  brush  the  inside  of  the  side  of  the 
vestibule  with  a  weak  (4  per  cent.)  solution  of  silver  ni- 
trate once  in  a  few  days  for  a  number  of  weeks. 

CORYZA;   ACUTE  NASAL  CATARRH;   ACUTE  PURULENT 
RHINITIS   (SNUFFLES,  IN   NURSERY   PARLANCE). 

32.  Acute  nasal  catarrh  is  the  most  common  of  all  dis- 
eases. Very  few  persons  pass  many  years  without  an 
attack.  The  well-formed  normal  nasal  passages  of  vig- 
orous individuals  may  not  be  invaded  for  a  number  of 
successive  years,  while  poor  health  and  especially  de- 
formed nasal  passages  and  chronic  intranasal  lesions  pre- 
dispose to  repeated  attacks  within  one  season.  Hered- 
itary syphilis  is  a  noteworthy  predisposing  condition  in 
infants.  No  age  is  exempt,  but  coryza  occurs  less  fre- 
quently after  middle  age  is  passed.  Least  common  dur- 
ing equable  weather  in  summer,  or  during  a  uniform  dry, 
cold  spell  in  winter,  it  is  most  prevalent  after  changeable 
weather  in  fall  and  spring.  Its  geographic  distribution, 
too,  corresponds  with  the  peculiarities  of  the  climate. 

The  attack  begins  with  sneezing,  followed  by  a  feeling 
of  fulness  in  the  nose  and  head,  which  culminates  after 
some  hours  in  nearly  total  occlusion  of  at  least  one  side 
of  the  nose,  sometimes  of  both.  At  the  same  time  there 
occurs  a  watery,  acrid  discharge,  becoming  purulent  in 
the   course   of    about    twenty-four   to   thirty-six   hours, 


CORYZA.  87 

after  which  time  the  secretion  is  a  thick,  purulent  mucus 
of  yellowish-greenish  tinge,  sometimes  slightly  bloody. 
The  full  feeling  increases  during  the  first  day,  and  is 
sometimes  accompanied  by  considerable  headache.  On 
account  of  the  swelling  around  the  Eustachian  orifice  the 
ears  may  feel  "stuffy."  In  children,  less  commonly  in 
adults,  a  febrile  rise  of  temperature  of  from  1°  to  3°  F. 
may  be  noticed.  Quite  often  a  general  feeling  of  malaise 
and  lassitude  is  felt.  The  tongue  becomes  coated,  the 
appetite  often  is  impaired,  all  the  more  so  as  the  sense  of 
smell  may  be  absent  and  hence  taste  interfered  with. 
The  smoker  refuses  his  cigar. 

In  the  typical  attack,  not  modified  by  preexisting 
chronic  nasal  disease,  this  condition  lasts  two  or  three 
days,  and  then  begins  to  decline.  The  nose  becomes 
clearer, — at  least  one  side  at  a  time, — although  the  dis- 
charge is  more  likely  to  increase  during  the  first  three 
days.  The  secretion  is  likely  to  cause  excoriation  of  the 
skin  at  the  entrance  of  the  nose,  which  in  its  turn  may 
prolong  the  annoyance.  The  discharge  changes  grad- 
ually into  clearer  mucus  with  purulent  fiakes.  In  un- 
complicated instances,  not  prolonged  by  exposure,  all 
symptoms  disappear  completely  in  from  six  to  ten  days. 

Inspection  shows  the  mucous  membrane  to  be  red- 
dened and  thickened.  The  occlusion  of  the  passage  is 
partly  due  to  turgescence  of  the  submucous  venous 
plexus.  This  may  be  overcome  transiently  by  the  pres- 
sure of  a  probe  or  by  the  action  of  cocain  or  suprarenal 
extract.  The  mucous  membrane,  however,  is,  besides, 
swollen  from  infiltration  with  leukocytes  and  serum. 
During  the  receding  period  the  vascularity  diminishes 
and  the  membrane  is  sometimes  seen  to  be  edematous — 
soggy.  Acute  rhinitis  is  a  diffuse  process  involving  the 
entire  lining  of  the  nose  uniformly.  Examination  with 
the  postnasal  mirror,  when  feasible,  shows  that  the  phar- 
yngeal tonsil  is,  as  a  rule,  involved,  being  reddened  and 
swollen,  though  to  a  variable  extent  in  different  patients. 
In  some  instances  the  inflammatory  redness  and  swelling 


88  DISEASES    OF    THE    NOSE. 

extend  visibly  along  the  pharyngeal  mucous  membrane 
down  below  the  level  of  the  soft  palate. 

Histologically,  coryza  is  a  diffuse  leukocytic  infiltra- 
tion, with  congestion  of  all  vessels,  especially  the  venous 
plexus,  and  with  partial  loss  of  the  ciliated  epithelium. 

Deviations  from  the  clinical  course,  as  described,  may 
occur  in  either  direction.  In  patients  with  either  chronic 
suppurative  or  hypertrophic  rhinitis  acute  exacerbations 
occur  with  symptoms  of  a  milder  character  than  in  the 
typical  attack.  The  climax,  which  is  not  so  severe  as 
in  a  hitherto  normal  nose,  is  reached  within  the  first  day, 
and  within  from  three  to  five  days  the  symptoms  subside 
to  the  grade  they  presented  prior  to  the  fresh  ' '  cold. ' ' 
Some  patients  give  the  history  of  frequent  "colds" 
lasting  only  a  few  hours.  These  are,  however,  not  in- 
flammatory attacks  at  all,  but  merely  spells  of  turgescence 
of  the  cavernous  tissue,  with  sneezing,  occlusion  of  the 
nose,  and  a  copious  watery  discharge  entirely  free  from 
pu.s.  On  the  other  hand,  nasal  stenosis  may  cause  a  pro- 
longation of  the  climax  for  several  days  and  may  lead  to 
an  indefinite  persistence  of  the  symptoms  during  the 
declining  stage.  Delay  in  the  disappearance  of  an  acute 
coryza  may  also  be  caused  by  exposure  to  inclement 
weather  and  insufficient  protection  against  cold. 

In  the  light  of  our  present  knowledge  we  cannot  but 
attribute  acute  purulent  rhinitis  to  the  action  of  some 
widely  distributed  parasite.  In  spite  of  many  attempts 
the  virus  has  not  yet  been  identified.  At  times  coryza 
attacks  a  number  of  persons  in  a  household  in  succession, 
so  that  a  suspicion  of  contagiousness  seems  warranted. 
Direct  inoculations,  however,  with  the  discharge  have 
failed  to  transfer  the  disease.  The  presence  of  various 
forms  of  pyogenic  cocci  during  the  declining  stage,  and 
especially  in  protracted  nasal  suppuration,  makes  it  prob- 
able that  secondary  infection  often  plays  a  role.  Popu- 
larly, acute  catarrh  is  always  ascribed  to  "  taking  cold." 
As  stated  in  Chapter  II.,  there  is  no  reason  to  doubt  that 
chilling  is  an  important   factor  in  causing  chronic  cir- 


CORYZA.  89 

cu inscribed  inflammatory  processes  to  become  acute  and 
diffused.  The  fact,  however,  that  the  same  chilling  of 
the  body  does  not  always  or  even  often  lead  to  the  same 
result  signifies  that  it  must  coincide  with  other  influ- 
ences which  we  do  not  know.  In  the  acute  catarrh  of 
hitherto  normal  noses  the  chance  of  satisfactory  inquiry 
is  so  rarely  afforded  to  the  physician  that  a  definite  opin- 
ion concerning  the  importance  of  "  taking  cold  "  cannot 
be  given. 

An  acute  purulent  rhinitis  is  often  a  part  of  the  clinical 
picture  of  influenza,  although  this  disease  may  also  occur 
without  it.  In  measles  there  is  always  an  inflammatory 
condition  of  the  nose,  with  watery  discharge  as  the  first 
manifestation.  In  some  instances  the  nasal  symptoms 
subside  without  suppuration  as  soon  as  the  cutaneous 
eruption  has  appeared;  in  others  they  develop  into  an 
ordinary  coryza  which  is  apt  to  be  prolonged  in  a  sub- 
acute form. 

Coryza  involves  no  danger  to  life  in  the  adult.  In 
infancy,  when  the  nasal  passages  are  relatively  narrow,  it 
may  be  accompanied  by  great  swelling  (and  subsequent 
hypertrophy  of  the  pharyngeal  tonsil),  and  the  inter- 
ference with  nasal  respiration,  causing  dyspnea  and  rest- 
lessness, gives  the  appearance  of  serious  danger.  But, 
after  all,  fatal  issues  must  be  very  uncommon,  if  they 
ever  do  occur  in  uncomplicated  cases.  A  serious  danger 
in  infants  is  the  possible  complication  with  bronchitis 
and  bronchopneumonia.  Although  complete  spontaneous 
recovery  is  by  far  the  most  common  result,  acute  catarrh 
may  change  into  a  persistent  chronic  inflammation  if 
there  is  nasal  stenosis,  if  it  be  prolonged  by  exposure,  or 
if  often  recurrent.  The  acute  inflammation  may  also 
extend  into  the  accessory  cavities.  This  is  probably  the 
case  more  often  than  is  now  taught,  especially  so  far  as 
the  ethmoid  cells  and  sphenoid  sinus  are  concerned,  and 
the  severe  headache  sometimes  present  during  a  "  cold  " 
is  probably  due  to  this  extension.  However,  most  of  the 
acute  inflammations  of  the  sinuses  heal  spontaneously. 


go  DISEASES    OF   THE   NOSE. 

Quite  often  acute  rhinitis  is  attended  with  acute  con- 
junctivitis, which  can  be  improved  by  treatment  (zinc 
sulphate  solution,  0.5  per  cent.,  or  brushing  with  silver 
nitrate  solution,  i  to  2  per  cent.),  but  not  entirely  cured 
until  the  nose  has  become  normal.  The  greatest  danger 
of  the  disease  is  the  extension  into  the  ear,  as  secretory 
catarrh  or  acute  purulent  otitis — most  likely  when  there 
is  nasal  stenosis.  Cor>-za  is  rarely  followed  by  tonsillitis, 
more  often  by  tracheitis  and  bronchitis. 

The  diagnosis  depends  upon  the  acute  nasal  obstruc- 
tion and  purulent  discharge.  In  doubtful  cases  inspec- 
tion must  not  be  omitted.  A  careless  observer  may 
make  the  diagnosis  of  simple  coryza  in  cases  of  mem- 
branous or  diphtheritic  rhinitis,  abscess  of  the  septum, 
and  in  diphtheritic  and  non-diphtheritic  inflammation  of 
the  pharyngeal  tonsil.  Genuine  coryza  must  be  differ- 
entiated also  from  acute  but  transient  non-inflammatory 
vasomotor  disturbances  (spells  of  turgescence)  in  which 
there  is  no  purulent  discharge,  and  from  the  effects  of 
iodism  upon  the  nose.  In  iodin  poisoning  there  is 
likewise  no  purulent,  but  merely  a  watery,  secretion, 
although  later  on  a  secondary  infection  may  change  the 
character  of  the  fluid.  Moreover,  the  iodin  effect  ceases 
speedily  on  withdrawing  the  drug. 

There  is  no  treatment  that  can  be  considered  curative 
or  even  permanently  palliative.  All  statements  concern- 
ing therapeutic  results  are  merely  copied  from  one  book 
to  another,  or  bear  the  stamp  of  hasty  and  unfounded 
generalization,  and  are  found  to  be  untrue  when  tested 
clinically.  The  popular  belief  in  the  abortive  effect  of 
quinin  is  a  myth.  Coryza  cannot  be  aborted  any  more 
than  any  other  infectious  disease  for  which  we  possess  no 
specific  treatment.  Cocain  gives  momentary'  relief,  but 
no  permanent  benefit.  The  same  is  true  of  the  douche. 
Suprarenal  solution  as  a  spray  (2  to  5  per  cent.)  has  a 
more  lasting,  even  if  transient,  palliative  effect,  and  is 
less  objectionable  than  cocain.  The  quickest  course  is 
observed   if  the   patient  stays   in   the   uniformly  warm 


COKYZA.  91 

room  and  avoids  physical  exertion.  The  headache  of 
accompanying  sinus  involvement  can  be  checked  by 
antipyrin  in  the  dose  of  i  gram  for  an  adult.  The  ex- 
coriations of  the  skin  under  the  nose  heal  under  any 
bland  salve  (oxid  of  zinc  ointment  or  cold  cream).  The 
treatment  of  subacute  exacerbations  and  chronic  pro- 
longation will  be  found  in  Chapter  V. 


CHAPTER   V. 

CHRONIC    NASAL    INFLAMMATIONS;    "CHRONIC 
CATARRH";   CHRONIC  PURULENT  RHINITIS. 

33.  Chronic  Catarrh. — The  various  forms  of  chronic 
nasal  disease  give  rise  to  very  similar  symptoms — viz., 
discharge  and  obstruction.  These  symptoms  were  hence 
referred  by  the  older  writers,  and  are  still  by  the  pub- 
lic, to  the  existence  of  a  "chronic  catarrh."  The  so- 
called  "catarrh,"  however,  can  be  resolved  into  a  num- 
ber of  separate  aflfections  and  lesions,  varying  in  character 
and  significance.  This  clinical  analysis  is  made  difficult 
by  the  frequent  coexistence  of  several  lesions  in  the  nose 
or  throat.  By  selecting  from  a  larger  experience  those 
cases  in  which  only  single  lesions  are  present,  certain 
types  of  nasal  and  nasopharyngeal  disease  can  be  estab- 
lished, which  the  diagnostician  must  recognize  whether 
they  occur  in  uncomplicated  or  in  associated  forms.  The 
special  term  "chronic  catarrh,"  if  it  is  to  be  applied  in 
its  conventional  sense  to  a  chronic  inflammation  of  a 
mucous  membrane  attended  with  mucous  discharge,  may 
be  reserved  for  that  form  of  nasal  disease  in  w^hich  there 
is  an  excessive  production  of  mucus — viz.,  retronasal 
catarrh.  The  ordinary  chronic  nasal  and  pharyngeal 
ajBfections  comprised  under  the  generic  term  "catarrh" 
can  be  classified  under  the  foUowinsf  heads : 


Suppurative    forms 
of  inflammation. 


With  ordinary  purulent  J  Chronic      purulent      rhinitis. 

discharge.  |        Suppuration  of  the    acces- 

t       sory  cavities. 

Ozena  (fetid  atrophic  rhinitis; 

simple     atrophic    rhinitis ; 

anterior      "  dry "      rhinitis 

(round  ulcer  of  septum). 


With  modified  purulent 
discbarge. 


Non-suppurative        f  With  raucous  discharge.  Retronasal  catarrh. 

inflammation.         i   Without  discharge.          J  /P        P 

«.  Hjrpertrophic  pharyngitis. 

92 


Sequels  of  inflam- 
mation. 


CHRONIC    PURULENT    RHINITIS.  93 

Deformities  of  the  septum. 

Enlargement  of  cavernous  tissue. 

Diffuse  hypertrophy  of  mucous  membrane. 

Circumscribed  hypertrophy  of  mucous  membrane  (polypi). 

Hypertrophies  of  pharyngeal  adenoid  tissue. 


It  will  be  most  serviceable,  however,  to  describe  these 
affections  in  an  order  differing  somewhat  from  the  one 
best  adapted  for  classification. 

34.  Chronic  Purulent  Rhinitis. — Symptoms. — Puru- 
lent rhinitis  is  characterized  by  the  discharge  of  pus  from 
the  nose.  As  this  symptom  is  common  to  various  diseases, 
it  must  be  determined  in  every  case  whether  the  pus 
comes  from  the  nasal  cavity  itself,  the  roof  of  the  phar- 
ynx, or  from  one  or  more  of  the  accessory  sinuses.  Accord- 
ing to  the  area  involved  in  the  disease  the  amount  may  vary 
from  large  masses  of  pus,  viscid  by  reason  of  the  mucin 
present,  to  trifling  flakes  that  are  easily  overlooked.  Some 
text-books  speak  of  the  occurrence  of  a  catarrhal  dis- 
charge. This  term  is  likely  to  lead  to  error.  In 
many  forms  of  nasal  disease  the  mucous  membrane  is 
abnormally  irritable  and  secretes  freel)-  in  response  to 
irritation  by  dust  or  chilling  of  the  body.  When  abun- 
dant, this  fluid  is  watery,  but  when  scant,  it  is  very 
thick  and  viscid.  This  transient  discharge  is  either 
entirely  clear,  indicating  the  absence  of  suppuration,  or, 
when  it  occurs  in  connection  with  any  purulent  process, 
it  is  mixed  with  streaks  of  pus.  Very  scant  purulent  dis- 
charge may  escape  detection  until  the  flakes  are  looked 
for  in  the  water  after  douching  the  nose.  Although  the 
discharge  is  mostly  blown  out,  it  may  pass  also  into  the 
pharynx  when  formed  in  the  posterior  regions,  or  be 
guided  thence  by  a  stenosis  anterior  to  the  secreting 
region.  The  swallowing  of  copious  purulent  secretion 
may  give  rise  to  stomach  disorders. 

The  other  symptoms  of  purulent  rhinitis,  variable  in 
different  cases,  are  transient  obstruction  from  the  presence 
of  pus  or  from  vascular  turgescence,  and  irritability,  as 
shown  by  fits  of  sneezing  and  momentary  water);  flow. 


94  CHRONIC    NASAL   INFLAMMATIONS. 

Many  patients  are  so  little  annoyed  by  the  disease  that 
the  diagnosis  is  made  only  incidentally  when  ear  or 
throat  complications  arise. 

Etiology. — Chronic  nasal  suppuration  is  not  a  morbid 
entity,  but  may  depend  upon  a  variety  of  conditions 
which  require  detection  in  the  individual  case.  Acute 
purulent  rhinitis,  especially  when  it  is  a  manifestation 
of  influenza,  is  likely  to  become  chronic  under  certain 
circumstances.  These  are  sometimes  constitutional  dis- 
turbances, chlorosis,  malnutrition  from  other  enfeebling 
diseases,  and  dyspepsia.  Quite  often  the  history  is  that 
of  recurrent  acute  attacks,  which  finally  become  perma- 
nent, especially  when  exposure  to  "cold,"  insufficient 
protection,  and  longer  spells  of  unfavorable  weather  have 
interfered  with  spontaneous  recovery.  Most  commonly, 
however,  local  lesions  will  be  found  that  account  for  the 
persistence  of  the  disease.  These  are,  in  general,  narrow- 
ness of  the  nasal  passages,  localized  stenosis  from  de- 
formities of  the  septum  or  spurs  on  its  surface,  or  cir- 
cumscribed hypertrophies  of  the  mucous  membrane  in 
the  form  of  papillomatous  tumors  upon  the  inferior 
turbinal,  or  polypi  from  the  middle  turbinal  or  external 
wall.  Relatively  often  nasal  suppuration  is  maintained 
by  the  enlarged  pharyngeal  tonsil  in  children  or  young 
adults.  The  presence  of  foreign  bodies  or  of  concretions 
may  protract  a  nasal  discharge  indefinitely  ;  in  such  a 
case  it  is  most  likely  to  be  one-sided. 

Pathology. — Examination  shows  that  the  purulent  in- 
flammation is  rarely  an  extensive  or  a  diffiise  process;  more 
often  it  is  a  localized  condition,  especially  in  the  upper 
recesses.  In  the  diffuse  form  the  entire  mucous  mem- 
brane is  reddened,  but  not  much  swollen.  Even  when 
a  localized  focus  exists,  a  diffuse  redness  may  be  due  to 
the  coexistence  of  a  diffuse  non-suppurating,  but  hyper- 
trophic inflammation,  a  not  infrequent  clinical  combina- 
tion. On  the  other  hand,  the  entire  lower  intranasal 
area  may  appear  normal.  Sometimes  the  source  of  the 
discharge  may  be  detected  in  a  limited  injected  part  of 


CHRONIC    PURULENT    RHINITIS.  95 

the  surface  high  up,  the  vulnerability  of  which  is  shown 
by  bleeding  when  touched  with  the  probe,  or  which 
is  covered  with  granulations.  Exposed  bone  is  never 
found  in  simple  purulent  rhinitis.  Its  detection  signifies 
syphilis  or  deep  involvement  of  the  ethmoid  cells.  In 
every  case  of  nasal  suppuration  in  which  the  discharge 
amounts  to  more  than  small  flakes  of  pus,  repeated  efforts 
must  be  made  to  ascertain  or  exclude  involvement  of  any 
of  the  accessory  cavities,  according  to  the  methods  to  be 
described  (1  40). 

In  a  large  proportion  of  cases  purulent  discharge  from 
the  nose  comes  from  one  or  more  of  the  accessory  sinuses. 
Fetor  of  the  discharge,  especially  if  one-sided,  suggests 
the  possibility  of  a  foreign  body,  particularly  in  children, 
or  of  a  concretion  (rhinolith).  The  diagnosis  can  easily 
be  made  with  the  probe. 

In  ordinary  cases  of  uncomplicated  purulent  rhinitis 
the  discharge  is  not  fetid.  Sometimes,  however,  the 
discharge  is  retained  by  swelling  of  the  mucous  mem- 
brane, due  to  circumscribed  edema  or  granulating  sur- 
faces. It  becomes  inspissated,  cheesy  in  appearance,  and 
horribly  offensive.  This  constitutes  the  rare  form  de- 
scribed as  rhinitis  caseosa.  There  is  usually  very  much 
nasal  obstruction  in  this  form.  By  thorough  removal  of 
the  pent-up  secretion  by  irrigation  it  is  changed  into  the 
ordinary  purulent  rhinitis,  which  then  yields  readily  to 
treatment. 

Uncomplicated  chronic  purulent  rhinitis  may  disap- 
pear without  treatment  under  improved  climatic  and 
hygienic  environment.  As  a  rule,  however,  it  does  not 
heal  entirely  during  the  warm  season,  but  merely  im- 
proves until  unfavorable  weather  returns.  Possible  com- 
plications to  which  it  may  lead  are  chronic  conjuncti- 
vitis, purulent  inflammation  of  the  tear-sac,  ear  disease 
(usually  the  secretory  catarrh  in  a  persistent  form), 
chronic  hypertrophic  pharyngitis,  and  laryngitis  or  bron- 
chitis. 

Treatment. — The  treatment  is  ordinarily  successful  if 


96 


CHRONIC    NASAL   INFLAMMATIONS, 


properly  individualized.  It  may  succeed  in  a  few  days  or 
may  require  many  weeks.  Faulty  habits  should  be  cor- 
rected, insufficient  clothing,  exposure  to  dust  and  weather, 
cold  feet,  constipation,  stomach  disturbances,  or  anemia 
should  receive  attention  (see  1 14  to  1 17).  Local  treat- 
ment demands  removal  of  the  pus,  as  this  fluid  is  too 
viscid  to  drain  off  without  aid,  especially  when  anatomic 
configuration  favors  its  confinement.  The  most  efficient 
measure  is  the  douche,  which  is  to  be  used  daily — even 
several  times  a  day  (see  1  25).  Irrigation  through  a 
small  cannula  (Fig.  32)  may  prove  more  satisfactory 
when  hidden  recesses  are  to  be  reached.     A  few  days' 

* .  _  11  cm. ^ 


Fig.  32. — Griinwald's  irrigating  tubes. 

steady  use  shows  either  the  benefit  of  irrigation  or  its 
inefficiency  in  a  given  case.  With  abundant  secretion 
and  fairly  wide  passages  the  douche  may  be  intrusted  to 
the  patient.  In  nasal  stenosis  this  would  be  contra- 
indicated  by  the  risk  to  the  ear,  and  we  must  rely  upon 
the  use  of  a  spray.  Yet  a  spray  from  even  a  good  atom- 
izer is  not  an  efficient  substitute  for  the  douche  for  the 
purpose  of  removing  pus,  especially  if  this  be  dammed  up. 
The  addition  of  medicaments  to  the  spray  solution  exerts 
but  little  influence,  as  its  effect  is  practically  mechanical. 
A  I  per  cent,  solution  of  sodium  bicarbonate  or  the  pleas- 
ant solution  of  ethereal  oils  (1  25)  may  be  used. 


SUBACUTE    RHINITIS    OF    SCROFULOUS    CHILDREN.  97 

When  a  circumscribed  area  of  pathologically  changed 
mucous  membrane  can  be  detected,  it  should  be  treated 
by  direct  localized  application.  Localized  surface  in- 
flammation yields  to  a  few  brushings  with  silver  nitrate 
solution  (5  to  10  per  cent.),  while  a  granulation  spot  will 
react  well  to  superficial  cauterization  with  trichloracetic 
acid. 

Some  cases,  however,  prove  rebellious.  In  most  of 
these  the  hindrance  to  a  cure  will  be  found  in  structural 
configuration,  causing  either  stenosis  or  local  damming 
up  of  pus.  Some  of  these  lesions  should  receive  surgical 
attention  at  once — for  instance,  papillomatous  tumors, 
polypi,  and  flabby  hypertrophies  of  the  furbinals ;  espe- 
cially, however,  any  existing  hypertrophy  of  the  pharyn- 
geal tonsil.  The  same  statement  applies  to  deformities 
of  the  septum  of  sufficient  degree  to  cause  stenosis  ;  but 
in  the  case  of  septum  deviations  or  ridges  of  minor  de- 
gree, an  individual  study  and  a  proper  trial  of  irrigation 
should  precede  the  decision  to  resort  to  operative  meas- 
ures. 

Besides  the  atypical  form  of  purulent  rhinitis  just 
described,  some  more  definitely  characterized  varieties 
may  be  recognized. 

35.  The  subacute  rhinitis  of  scrofulous  children 
begins  as  a  mild  or  subacute, nasal  suppuration,  and  per- 
sists until  mild  weather  arrives  or  until  it  is  successfully 
treated ;  often,  however,  it  recurs  the  next  season.  The 
subjects  are  typically  scrofulous  young  children  with 
tubercular  glands  in  the  neck.  The  discharge  is  rela- 
tively thin,  mucopurulent,  and  leads  to  excoriations  and 
eczema  below  the  nose.  There  is,  as  a  rule,  moderate 
enlargement  of  the  pharyngeal  tonsil ;  rarely,  excessive 
nasal  obstruction.  The  disease  is  often  associated  with 
phlyctenular  keratoconjunctivitis,  and  frequently  causes 
purulent  otitis.  A  cure  is  sometimes  obtained  by  better 
protection  and  healing  of  the  excoriations  under  the 
nose  by  silver  nitrate  (lo  per  cent.)  applications,  followed 
by  a  zinc  or  ichthyol-lanolin  salve  or  oil  of  cade.  Cod- 
7 


98  CHRONIC    NASAL    INFLAMMATIONS. 

liver  oil  is  generally  of  benefit.  The  same  may  be  said 
of  all  hygienic  measures  directed  against  scrofula,  such 
as  fresh  air,  baths,  and  proper  feeding.  The  douche  is 
very  useful,  unless  a  hypertrophic  pharyngeal  tonsil  con- 
traindicates  its  use,  in  which  case  a  spray  must  take  its 
place.  Any  enlargement  of  the  pharyngeal  tonsil  that 
causes  symptoms  of  obstruction  calls  for  its  removal. 
This  does  not,  however,  necessarily  cure  the  rhinitis, 
although  always  of  beneficial  influence.  As  the  children 
approach  puberty  the  relapses  cease. 

36.  Another  variety  has  been  named  "purulent  rhi- 
nitis of  children"  (Bosworth).  It  is  a  typical,  but  not 
very  common,  affection.  Its  subjects  are  not  necessa- 
rily scrofulous.  It  begins  early  in  childhood,  and  if  not 
checked,  persists  during  adolescence.  In  a  few  instances 
the  author  has  known  it  to  cease  spontaneously.  The 
discharge  is  thick,  very  profuse,  not  fetid,  and  but  little 
influenced  by  the  season.  Examination,  difficult  in  chil- 
dren, does  not  show  the  origin  of  this  profuse  flow  of 
mucopus.  It  begins  before  the  accessory  cavities  are 
well  developed.  The  nasal  lining  appears  pale.  The 
passages  are,  as  a  rule,  roomy,  especially  the  pharynx. 
The  pharyngeal  tonsil  is  often  normal.  When  enlarged, 
its  removal,  even  if  otherwise  indicated,  does  not  dimin- 
ish the  secretion  of  pus,  at  least  not  for  many  weeks, 
perhaps  ultimately.  Like  all  purulent  nasal  affections, 
it  menaces  the  ear,  often  leading  to  purulent  otitis  with 
tendency  to  relapses.  A  view  expressed  by  Bosworth 
that  this  form  of  purulent  rhinitis  may  be  the  first  stage 
of  ozena  has  not  been  confirmed  by  any  one,  and  was 
disproved  in  the  author's  experience  by  several  observa- 
tions continued  through  a  number  of  years.  The  disease 
can  be  cured  by  the  persistent  use  of  the  douche  for 
many  months. 

37*  Nasal  suppuration  was  not  distinguished  sharply  from 
the  non-suppurative  forms  of  rhinitis  in  former  text-books.  It  is 
only  within  the  last  ten  years  that  it  has  been  shown  by  Ziem, 
and  later  by  others,  especially  Griinwald,  that  many  cases  of  so- 


"purulent  rhinitis  of  children."  99 

called  purulent  rhinitis  are  really  sinus  affections.  Perhaps  the 
clearest  exposition  of  suppurative  affections  of  the  nose  and  its 
adjoining  cavities  can  be  found  in  Griinwald's  Lehre  von  den 
Naseneiterungen,  second  edition,  1896  (American  edition,  Treatise 
on  Nasal  Suppuration,  1900).  The  purulent  rhinitis  of  children 
was  described  by  Bos  worth  in  his  Diseases  of  the  Nose  and 
Throat,  1889.  The  form  I  have  described  as  subacute  rhinitis  of 
scrofulous  children  has  not  been  differentiated  clearly,  except  by 
Klemperer  in  Heymann's  Handbuch  der  Laryngologie,  etc.  It  is, 
however,  a  clinical  picture  quite  familiar  to  ophthalmologists. 


CHAPTER  VI. 

DISEASES  OF  THE   NASAL  ACCESSORY   CAVITIES. 

38.  In  communication  with  the  nasal  passages  are  the 
six  hollow  sinuses  or  cavities — viz.,  in  the  superior  maxil- 
lary, the  frontal  and  the  sphenoid  bones,  as  well  as  a  series 
of  cellular  spaces  in  the  ethmoid  bone.  They  are  all  lined 
by  a  thin  mucous  membrane  continuous  with  that  of  the 
nose  and  inseparable  from  the  periosteal  lining.  Nothing 
is  known  concerning  the  utility  of  these  spaces,  except 
that  they  lessen  the  weight  of  the  head.  While  only  the 
severest  type  of  disease  of  the  sinuses  was  formerly  recog- 
nized as  a  very  rare  surgical  accident,  it  has  been  learned 
within  the  past  ten  years  that  affections  of  these  spaces 
are  very  common.  Their  remarkable  frequency  has  been 
shown  even  more  strikingly  by  autopsies  than  by  clinical 
experience.  Systematic  researches  have  been  made  on 
the  postmortem  table  by  Harke,  E.  Frankel,  Dmochowski, 
Wolff,  Pierce,  and  others.  It  has  thus  been  shown  that 
one  or  more  of  the  sinuses  are  found  diseased  in  nearly 
one-half  of  unselected  subjects  dead  from  different  causes. 
In  diseases  of  the  respiratory  passages  the  ratio  is  even 
higher,  and  in  infectious  diseases,  like  diphtheria  and 
scarlet  fever,  involvement  of  some  of  the  cavities  is 
almost  the  invariable  rule.  The  sinus  involved  most 
commonly  is  the  maxillary  antrum;  about  one-half  as 
often  the  sphenoid  cavity  is  found  diseased,  while  the 
frontal  sinus  suffers  relatively  rarely.  The  ethmoid  cells 
have  not  been  examined  to  the  same  extent,  and  there  is 
some  discrepancy  as  regards  the  frequency  of  their  in- 
volvement by  different  authors.  They  are  evidently  much 
less  often  diseased  than  the  maxillary  sinus.  Relatively 
common  is  multiple  disease  of  several  sinuses. 

The  lesions  found  vary  from  a  mild  superficial  to  a 
100 


SYMPTOMS    OF   SINUS    DISEASE.  lOI 

deep-seated  inflammation,  with  more  or  less  loss  of  epi- 
thelium and  sometimes  with  membranous  formation, 
while  the  contents  of  these  spaces  may  be  a  turbid 
serum  or  pure  pus.  There  is  usually  much  inflamma- 
tory edema  present. 

The  involvement  of  the  accessory  cavities  in  severe 
systemic  disease  occurs  either  but  shortly  before  death, 
or  produces  so  little  symptomatic  manifestation  that  it 
has  hitherto  been  practically  overlooked  clinically,  as 
acute  affections  of  the  sinuses  are  not  often  seen  clinic- 
ally, while  of  the  chronic  instances  only  a  moderate  pro- 
portion can  be  traced  to  some  previous  general  disease. 
Still,  among  the  patients  presenting  a  purulent  discharge 
from  the  nose  a  large  number  really  suffer  from  disease 
of  one  or  the  other  sinus. 

39.  Symptoms  of  Sinus  Disease. — Prominent  among 
the  symptoms  of  acute  sinus  disease  is  pain.  This  may 
occur  in  the  form  of  headache,  especially  in  the  case  of 
the  sphenoid  and  ethmoid  spaces.  Disease  of  the  frontal 
sinus  commonly  causes  supra-orbital  neuralgia  or  tempo- 
ral headache — one-sided  if  the  lesion  is  unilateral.  In- 
flammation of  the  maxillary  sinus  produces  infra-orbital 
neuralgia  and  pain  in  the  teeth  of  the  upper  jaw.  The 
localization  of  the  pain  is,  however,  not  absolutely  diag- 
nostic of  the  sinus  involved.  Corresponding  to  the  seat 
of  disease  are  spots  of  tenderness  during  the  acute  period 
— viz.,  over  and  under  the  brow  when  the  frontal  sinus 
suffers,  and  under  the  orbit  when  the  maxillary  space  is 
involved.  In  chronic  instances  the  same  forms  of  head- 
ache and  of  neuralgia  may  be  present,  especially  in  neu- 
rotic subjects,  but  they  are  not  so  constant.  Suppuration 
of  the  ethmoid  and  sphenoid  cells  is  at  times  the  source  of 
periodic  attacks  of  migrain.  Sometimes  chronic  sinuitis 
is  not  attended  by  pain,  especially  when  the  escape  of 
pus  is  not  obstructed.  Patients  with  sinuitis  are  often 
noticeably  intolerant  to  alcohol.  Pronounced  mental  de- 
pression is  not  uncommon. 

At  its  onset  acute   sinuitis   causes   the  systemic   dis- 


102  DISEASES    OF    THE    NASAL    ACCESSORY    CAVITIES. 

comforts  of  infectious  disease — viz.,  slight  fever,  lassitude, 
and  loss  of  appetite.  In  chronic  cases,  too,  systemic  affec- 
tion may  occur  in  the  form  of  stomach  disturbance,  per- 
haps due  to  the  swallowing  of  the  discharge,  as  well  as 
loss  of  vigor  and  general  malnutrition.  Continued  sup- 
puration may  lead  to  neurasthenia,  especially  when  pain 
helps  to  depress  the  nervous  system.  The  direct  nasal 
symptoms  of  sinus  disease  are  more  or  less  obstruction — 
its  degree  dependent  upon  the  width  of  the  passage — and 
purulent  discharge.  The  latter  may  be  very  slight  or 
extremely  copious,  bland  or  foul.  Some  patients  pay  no 
attention  to  the  slight  discharge;  in  others  it  may  drop 
into  the  pharynx.  Not  rarely  nasal  lesions  are  associated 
with  sinus  disease,  such  as  purulent  or  hypertrophic 
rhinitis,  and  especially  polypi.  These  lesions  are  either 
the  consequence  of  sinus  suppuration,  or,  if  preexistent, 
are  a  predisposing  condition.  The  latter  statement  ap- 
plies especially  to  ozena.  Often,  too,  sinus  inflammation 
leads  ultimately  to  disease  of  the  pharynx  or  larynx  or 
the  bronchial  tubes.  Occasionally  inflammation  of  a 
cavity,  especially  the  ethmoid  cells,  is  the  starting-point 
of  asthma. 

Complications. — Among  the  dangers  of  all  sinus  dis- 
ease are  the  possible  invasion  of,  or  influence  upon,  ad- 
joining organs.  The  ear  may  suffer  from  acute  puru- 
lent otitis  or  serous  catarrh.  Extension  toward  the  eye 
may  involve  the  tear-passages  in  the  form  of  purulent 
inflammation.  Suppuration  of  either  the  frontal  or  the 
ethmoid  cavities  may  lead  to  bulging  of  the  orbital  wall 
of  these  spaces,  simulating  an  orbital  abscess.  More 
serious  is  the  actual  perforation  of  this  wall,  with  invasion 
of  the  orbit  itself,  although  the  true  orbital  abscess  may 
also  follow  a  benign  course.  Some  of  the  intra-ocular 
tissues  sometimes  suffer  in  consequence  of  different  forms 
of  sinuitis.  In  the  course  of  ethmoid  or  maxillary  sup- 
puration iritis  of  a  very  persistent  character  with  great 
liability  to  relapse  may  occur.  Atypical  forms  of  cho- 
rioretinitis and  of  exudative  choroiditis  have  also  been 


PATHOLOGY.  IO3 

observed  as  a  complication  of  these  sinus  diseases.  Sup- 
puration of  the  sphenoid  space  has  in  rare  instances  led 
to  inflammatory  involvement  or  to  atrophy  of  the  optic 
nerve,  separated  from  the  sinus  only  by  bony  walls  of 
variable  thinness.  Any  form  of  sinus  disease  may 
result  in  irritability  of  the  eyes  and  obstinate  asthe- 
nopia. 

Deaths  have  been  recorded  in  moderate  number  in 
consequence  of  extension  of  sinus  disease  to  the  brain. 
This,  however,  is  not  a  frequent  accident  and  does  not 
apply  to  disease  of  the  maxillary  sinus. 

Pathology. — The  lesions  in  acute  sinuitis  as  observed 
at  autopsies  vary  from  a  superficial  inflammation  to  an 
involvement  of  the  deep  periosteal  layer,  with  more  or 
less  edema  and  sometimes  ecchymoses.  The  epithelium 
may  be  intact  or  partially  lost.  Croupous  and  pseudo- 
diphtheritic  inflammation  is  less  common.  In  chronic 
cases  studied  during  operations  the  mucous  membrane  is 
usually  found  thickened;  occasionally,  in  a  state  of  cys- 
toid  degeneration;  in  other  instances,  tough  and  sclerosed. 
Polypi  are  not  often  met  with.  Prolonged  deep  inflam- 
mation may  lead  to  roughening  of  the  bone  by  the  forma- 
tion of  osteophytes.  Granulation  tissue  is  quite  com- 
monly found.  When  pus  exudes  on  curetting  these 
granulations,  caries  of  the  bony  wall  exists  underneath, 
but  this  is  a  relatively  rare  lesion.  Occasionally  necrotic 
sequestra  of  bone  have  been  seen. 

Dilatation  of  a  sinus  with  bulging  of  one  of  its  walls 
occurs  not  very  rarely  in  the  case  of  the  frontal  and 
ethmoid  cavities,  evidently  on  account  of  an  occluded 
orifice.  Sometimes  the  contents  are  turbid  or  even  clear 
mucus,  and  the  process  is  due  to  retention  without  pyo- 
genic infection.  This  condition  has  been  termed  hydrops 
or  mucocele.  In  other  instances  pyogenic  influences 
complicate  and  pus  is  present,  usually  with  decided  ten- 
dency to  spontaneous  perforation.  Hydrops  of  the 
maxillary  sinus  is  likewise  a  not  uncommon  occurrence, 
but  does  not  cause  bulging  of  its  walls.     Indeed,   the 


I04  DISEASES    OF   THE    NASAL   ACCESSORY    CAVITIES. 

only  disease  that  leads  to  visible  distention  of  the  max- 
illary cavity  is  the  presence  of  dental  cysts  in  its  interior. 

etiology. — Antopsies  have  shown  that  the  most  com- 
mon causes  of  sinus  disease  are  severe  systemic  affections 
or  the  terminal  ^infections  that  produce  death.  Although 
pathologists  state  that  commonly  there  are  no  nasal 
lesions  in  such  cases,  it  is  more  logical  to  assume  that 
the  infection  occurs  oftener  through  the  nasal  orifice  of 
the  sinus  than  by  way  of  the  blood  current.  Fatal  diph- 
theria produces,  invariably,  fatal  influenza,  scarlet  fever, 
and  measles,  quite  commonly  disease  of  one  or  more  of 
the  cavities.  This  involvement  is  more  often  due  to 
secondary  infections  than  to  the  specific  parasites  of  the 
original  disease. 

But  of  the  sinus  affections  thus  produced,  relatively  few 
are  observed  clinically.  If  the  patient  does  not  die,  most 
of  these  forms  of  sinus  affection  get  well  spontaneously. 
It  is  evident  clinically  that  the  spontaneous  recovery  is 
hindered  by  any  conditions  interfering  with  drainage, 
such  as  coexisting  intranasal  lesions.  The  larger  pro- 
portion of  the  clinical  cases  of  sinus  disease  can  be  traced 
to  the  time  of  a  severe  nasal  inflammation,  either  simple 
coryza  or  more  often  the  nasal  affection  during  the  course 
of  an  influenza,  pneumonia,  typhoid  fever,  scarlet  fever, 
or  measles.  Less  commonly  syphilitic  nasal  disease  is 
the  original  cause.  Relatively  often  the  cavities  become 
involved  in  the  course  of  ozena.  Disease  of  the  higher 
sinuses  may  spread  into  the  maxillary  cavity  secondarily. 
Traumatism  plays  a  minor  role.  Intranasal  cauterization 
occasionally  causes  maxillary  or  frontal  involvement.  A 
large  minority  of  the  maxillary  cases  can  be  traced  to 
defective  teeth. 

The  parasites  found — and  presumably  the  cause  of  sinus 
disease — are  pneumococci,  staphylococci  (different  va- 
rieties), streptococci,  pseudodiphtheria  bacilli,  coli  bacilli, 
and  the  bacillus  mucosus  capsulatus  (ozena),  often  in  com- 
bination. In  influenza  the  influenza  bacillus  has  been 
found  less  often  than  other  parasites.     Diphtheria  of  the 


DIAGNOSIS — TREATMENT.  IO5 

nose  causes  always  diphtheritic  infection  of  some  sinuses 
(in  fatal  cases),  whereas  diphtheria  of  the  throat  leads  to 
sinus  disease,  but  not  necessarily  to  diphtheritic  infection 
of  the  sinus.  There  is  good  reason  to  believe  that  the 
long-continued  contagiousness  of  convalescent  diphtheria 
patients  is  partly  due  to  the  persistence  of  the  germs  in 
one  or  the  other  sinus. 

40.  Diagnosis. — The  diagnosis  of  any  sinus  suppura- 
tion depends  upon  the  demonstration  of  the  discharge. 
It  is  sometimes  very  difficult  to  trace  the  pus  to  its  source. 
The  frontal  and  the  maxillary  sinus  and  the  anterior 
ethmoid  cells  empty  their  morbid  contents  underneath 
the  middle  turbinal  near  its  anterior  end.  The  posterior 
ethmoid  cells  and  the  sphenoid  sinus  discharge  through 
the  space  between  the  middle  turbinal  and  septum. 
When  the  nose  is  filled  with  pus,  this  must  be  partly 
removed  by  mopping  before  the  path  of  entrance  can  be 
traced.  If  no  secretion  can  be  seen,  the  douche  will 
bring  out  any  discharge,  which  must  be  sought  in  the 
basin.  In  doubtful  cases  tampons  may  be  left  in  the 
middle  meatus  or  between  the  middle  turbinal  and  the 
septum  for  a  short  time  and  then  examined.  Probing 
through  the  natural  orifices  is  difficult,  but  generally 
possible  in  the  case  of  the  sphenoid  sinus;  less  successful 
in  the  case  of  the  frontal  sinus,  but  very  uncertain  so  far 
as  the  other  cavities  are  concerned.  Attempts  may  be 
made  to  dislodge  pus  by  directing  a  stream  through  a 
narrow  cannula  toward  the  natural  orifice  of  the  sus- 
pected space.  Maxillary  suppuration  can  usually  be 
demonstrated  by  translumination  (see  T[  49).  In  doubt- 
ful instances  the  diagnosis  can  be  made  certain  only  by 
an  exploratory  puncture. 

•  41.  Treatment. — The  treatment  of  acute  cases  may 
be  expectant  unless  urgent  symptoms  indicate  immediate 
operation.  Probably  most  acute  cases  heal  spontaneously. 
The  healing  is  favored  by  all  measures  that  facilitate 
drainage,  such  as  the  use  of  the  douche  and  frequent 
spraying  by  the  patient,  as  well  as  applications  of  cocain 


I06  DISEASES    OF    THE    NASAL    ACCESSORY    CAVITIES. 

or  suprarenal  solution,  while  obstructive  lesions  should 
receive  due  and,  if  necessary,  surgical  attention.  The 
acute  pain  can  generally  be  checked  by  antipyrin.  Neu- 
ralgic pains,  if  not  permanently  controlled  by  antipyrin, 
are  often  cured  by  the  use  of  quinin  in  large  doses  (0.4  to 
0.6  twice  a  day).  All  chronic  cases,  however,  in  which 
a  purulent  discharge  has  persisted  for  many  weeks 
require  operative  interference. 

While  the  special  operations  required  for  the  different 
sinuses  will  be  described  in  connection  with  each,  a  pro- 
cedure applicable  in  disease  of  the  anterior  ethmoid  cells, 
the  frontal  and  the  maxillary  sinus,  can  be  detailed  at 


Fig.  33. — Giiinwald's  cutting  forceps  for  operation  on  the  middle  turbinal. 

present.  It  is  resection  of  the  front  end  of  the  middle 
turbinal,  as  advocated  by  Griinwald.  By  the  removal  of 
this  overhanging  ledge  the  nasal  side  of  the  orifice  of  the 
spaces  is  made  accessible.  The  middle  turbinal  can- 
not always  be  grasped  sufficiently  by  the  wire  loop  of  the 
snare  to  be  removed  satisfactorily.  Hence  Griinwald  cuts 
the  front  part  of  its  lateral  attachment  with  a  specially 
designed  forceps  (Fig.  33).  Any  cutting  forceps,  how- 
ever, of  such  shape  as  to  reach  this  locality  can  be  sub- 
stituted. The  snare  loop  can  now  be  slid  through  the 
gap,  and  the  front  end  of  the  bony  lamella  may  thus  be 
snared  off.    When  the  lateral  insertion  cannot  be  reached 


ANATOMY    OF    THE    NASAL    ACCESSORY    CAVITIES.  10/ 

easily  by  forceps  on  account  of  its  height,  the  author 
has  cut  a  vertical  gap  through  the  middle  turbinal,  i  to 
2  cm.  behind  its  front  end,  and  then  grasped  the  anterior 
extremity  with  the  snare  through  this  gap,  thus  letting 
the  wire  cut  horizontally  instead  of  vertically,  as  Griin- 
wald  advocates. 

History  and  Literature. — Prior  to  1880  the  literature  of  sinus 
affections  consisted  mainly  in  the  reports  of  isolated  cases  of  suffi- 
cient severity  to  make  the  diagnosis  a  simple  matter.  The  fre- 
quency of  empyema  of  the  maxillary  sinus,  foreshadowed  in 
dental  literature,  was  emphasized  by  Ziem,  a  personal  sufferer 
from  that  disease,  in  many  reports  since  1880.  Attention  was 
called  to  ethmoid  disease  by  Woakes,  the  value  of  whose  clinical 
observations  was  impaired  by  false  pathologic  notions  concerning 
' '  necrosing  ethmoiditis. ' '  Numerous  reports  scattered  throughout 
periodic  literature  gradually  helped  to  establish  the  clinical  pic- 
ture of  sinuitis.  Disease  of  the  frontal  sinus  was  well  described 
and  appropriately  treated  in  Kuhnt's  treatise  (  Ueber  die  entzund- 
lichen  Erkrankunge?i  der  Stirnhohlen  und  ihre  Folgezustdnde,  1895). 
Extensive  autopsy  reports  began  with  Welch  selbaum,  but  espe- 
cially Harke  {Beitrdge  zu  Pathologic  der  oberen  Athmungswege, 
1895),  and  were  extended  by  E.  Frankel  and  others.  The  most  com- 
plete reviews  of  the  entire  subject  are  found  in  Griinwald's  Treat- 
ise on  Nasal  Suppuration,  Killian's  articles  in  Heyman's  Hand- 
buch  der  Laryngologie,  etc.,  but  especially  to  be  recommended  is 
Hajek's  Pathologic  und  Therapic  der  Nebcnhbhlen  der  Nase  (1899). 
The  last-named  treatise  and  Z\xQk.Q.x\ia.Vi^'^  Anatomie  der  Nasen- 
h'dhle  are  the  best  sources  of  anatomic  information. 


ANATOMY  OF  THE  NASAL  ACCESSORY  CAVITIES  AND 
THEIR  TOPOGRAPHIC  RELATION  TO  THE  NASAL  PAS- 
SAGES. 

42.  The  pneumatic  spaces  known  as  the  nasal  sinuses 
surround  the  external  wall  and  partly  the  roof  of  the 
nasal  cavity.  The  roof  begins  with  the  awning-shaped 
covering  of  the  vestibule  formed  by  the  nasal  bones. 
The  nasal  cavity  proper  is  closed  above  by  the  ethmoid 
bone  anteriorly,  and  by  the  body  of  the  sphenoid  bone 
posteriorly.  The  distance  from  the  floor  to  the  roof 
underneath  the  horizontal  plate  of  the  ethmoid  is  from 
38  to  ^o  mm.     Posterior  to  the  ethmoid  the  front  surface 


108  DISEASES    OF   THE    NASAL    ACCESSORY    CAVITIES. 

of  the  Sphenoid  body  falls  off  vertically,  with  a  back- 
ward slant,  and  thus  shortens  the  nasal  height  about 
15  mm.,  while,  by  reason  of  the  downward  slope  of  the 
lower  surface  of  the  sphenoid,  the  vertical  diameter  of 
the  nose  continues  to  diminish  toward  the  posterior 
choanae.  Of  that  part  of  the  roof  formed  by  the  hori- 
zontal or  cribriform  plate  of  the  ethmoid  only  about  2  to 
3  mm.  are  accessible  on  each  side  of  the  septum,  as  the 
various  ethmoid  lamellae  that  form  the  labyrinth  reduce 
the  width  of  the  olfactory  fissure  to  that  extent.  Under- 
neath the  sphenoid  the  width  of  the  roof  is  determined 
by  the  breadth  of  the  inferior  surface  of  the  sphenoid 
bone.  The  variable  thinness  of  the  ethmoid  roof  that 
separates  the  nose  from  the  intracranial  cavity  enjoins 
the  utmost  caution  in  operations  near  the  roof. 

The  external  wall  of  the  nasal  passage  is  formed  in  its 
anterior  two-thirds  by  the  nasal  surface  of  the  superior 
maxillary  below  and  by  the  lamina  papyracea  of  the  eth- 
moid bone  above,  while  the  posterior  third  is  made  up  of 
the  vertical  plate  of  the  palate  bone.  The  nasal  width 
between  the  external  walls  diminishes  upward,  but  the 
nasal  passage  itself  is  very  much  narrowed  by  the  turbi- 
nated processes.  The  turbinated  bone  (inferior  turbinal) 
runs  as  a  ledge  from  about  i  cm.  behind  the  nasal  aper- 
ture to  the  posterior  choanae.  By  its  external  articulation 
it  is  attached  to  the  maxillary  as  well  as  the  palate  bones. 
This  thin  curved  and  partly  rolled  lamina  presents  its 
convexity  upward  and  inward.  Its  posterior  end  appears 
broadened  by  reason  of  its  curve.  The  delicacy  of  this 
bony  ledge  is  hidden  by  the  thick  and  turgescent  mucous 
membrane  covering  it.  Nearly  parallel  with  and  above 
the  inferior  turbinal  is  the  middle  turbinal,  beginning 
anteriorly  about  i  cm.  behind  the  lower  one,  which  it 
resembles  in  shape.  The  middle  turbinal,  however, 
originates  from  the  lamina  papyracea  of  the  ethmoid,  but 
extends  beyond  that  bone  posteriorly  to  the  posterior 
choanse.  Between  it  and  the  external  wall  are  other 
bony  processes  of  the  ethmoid,    to  be   described  later 


ETHMOID    CELLS. 


109 


Above  it,  too,  are  additional  laminae  from  the  ethmoid 
bone  projecting  like  the  middle  turbinal  inward  and 
downward.     All  of  these  offshoots  of  the  ethmoid  narrow 


Fig.  34. — Frontal  section  through  the  rear  part  of  the  nasal  passages :  A, 
Roof;  B,  floor;  b,  external  wall  of  nasal  passages;  C,  alveolar  process,  high 
and  spongy ;  a,  a,  a,  the  three  nasal  nieati ;  b,  middle  turbinal ;  c,  olfactory 
fissure;  d,  respiratory  fissure  (Zuckerkandl). 

the  upper  part  of  the  nasal  passage  to  the  width  of  the 
olfactory  fissure  (Fig.  34). 


ETHMOID  CELLS. 

43.  The  key  to  the  complicated  architecture  of  the 
nasal  cavity  and  its  sinuses  is  furnished  by  the  anatomy 
of  the  ethmoid  bone  (Fig.  35).  Its  horizontal  or  cribriform 
plate  (lamina  cribrosa)  separates  the  nasal  from  the  intra- 
cranial cavity.  Its  width  corresponds  to  the  space  be- 
tween the  internal  boundaries  of  the  orbits.  From  this 
plate  descends  centrally  and  vertically  the  perpendicular 


I  lO  ANATOMY    OF    THE    NASAL   ACCESSORY    CAVITIES. 

lamina,  which,  by  articulating  with  the  nasal  bones  in 
front  and  with  the  anterior  surface  of  the  sphenoid  body 
behind,  forms  the  upper  part  of  the  nasal  septum. 

Above  the  cribriform  plate  the  prolongation  of  the 
perpendicular  lamella  extends  into  the  cranial  cavity  as 
a  short  sharp  ridge — the  crista  galli.  The  lateral  surface 
of  the  ethmoid  bone  is  formed  by  the  thin,  nearly  vertical 
lamina  papyracea,  which  constitutes  the  internal  wall  of 


Oe 


-  5plx.C. 


Lf.-- 


Fig.  35. — Ethmoid  bone  seen  from  the  left  side  :  /,  /,  The  orbital  surface  of 
the  lamina  papyracea;  C.  g,  crista  galli;  F.  c,  frontal  cellules;  C.  c,  lacrimal 
cellules ;  Z.  /,  perpendicular  plate ;  u.  /,  uncinate  process ;  M.  c,  maxillary 
cellules ;  M.  t,  middle  turbinal  process ;  S.  t,  superior  turbinal  process ;  Sph.  C, 
sphenoid  cellules. 

the  orbit.  This  plate  does  not  join  the  lamina  cribrosa. 
Instead  of  a  sharp  edge,  which  would  be  formed  by  the 
junction  of  upper  and  external  sides,  the  ethmoid  bone 
presents  here  a  series  of  pneumatic  cells  (foveolse  eth- 
moidales)  open  in  the  macerated  specimen,  but  closed  in 
situ  by  articulation  with  the  correspondingly  hollowed 
margin  of  the  orbital  plate  of  the  frontal  bone  (Fig.  36). 
Downward  the  lamina  papyracea  extends  to  the  (nasal) 
border  of  the  orbital  process  of  the   superior  maxilla. 


ETHMOID    CELLS. 


Ill 


The  two  laminae  papyracea  diverge   slightly  downward 
and  backward. 

From  the  internal  face  of  the  lamina  papyracea  arise  a 
series  of  more  or  less  concentric,  shelf-like  lamellae,  the 
ethmotnrbinal  processes.  Their  attachment  to  the  lam- 
ina papyracea  describes  a  slight  curve  with  its  convexity 
downward  from  the  anterior  upper  end  to  the  inferior 
lower  termination.  In  transverse  (frontal)  section  all 
these  processes  appear  curving  downward  so  as  to  form 
overhanging  ledges.     The  three  lowest  processes — viz., 


Fig.  36. — ^View  of  the  frontal  bone  from  the  pyriform  incisure,  showing  the 
pneumatic  spaces  which  form  part  of  the  upper  ethmoid  cells  (Hajek). 

the  uncinate  process,  ethmoid  bulla,  and  middle  turbinal 
— extend  downward  below  the  inferior  margin  of  the  lam- 
ina papyracea,  so  as  to  cover  a  part  of  the  gap  in  the 
nasal  surface  of  the  superior  maxilla. 

The  lowest  ethmotnrbinal  lamella  is  the  uncinate 
process  (Fig.  37).  This  delicate  broad-sword  or  sickle- 
shaped  bony  lamina  does  not  arise  from  the  lamina 
papyracea  itself,  but  from  the  anterior  expansion  of  the 
middle  turbinal  process,  where  the  latter  articulates  with 
the  frontal  process  of  the  superior  maxillary  bone. 


112 


ANATOMY    OF    THE    NASAL    ACCESSORY    CAVITIES. 


It  proceeds  backward  and  somewhat  downward  in  a 
plane  not  quite  vertical,  as  its  upper  concave  edge  points 
toward  the  maxillary  sinus.  Near  its  rear  end  this 
process  is  attached  by  delicate  prolongations  to  an  upward 
extension  of  the  inferior  turbinal  bone  and  to  the  roof  of 
the  maxillary  sinus.  The  internal  or  nasal  wall  of  the 
maxillary  sinus  has  a  large  aperture  in  its  upper  part  in 
the  skeleton.    The  space  between  the  lower  border  of  the 


Fig.  37. — External  wall  of  the  right  nasal  passage:  B,  Bulla  ethmoidalis; 
p,  uncinate  process;  H,  hiatus  semilunaris;  S,  sinus  within  the  bulla  ethmoid 
alis  (Zuckerkandl). 

uncinate  process  and  the  lower  rim  of  this  bony  aperture 
in  the  maxillary  wall  is  closed  by  the  junction  of  the 
mucous  membrane  of  the  nose  and  of  the  maxillary 
sinus,  which  two  linings  are  here  inseparable.  This  mem- 
branous wall,  containing  some  vertical  bridges  formed 
by  slender  spicules  of  bone,  is  termed  the  nasal  fontanel. 
Above  (and  behind)  the  uncinate  process  there  springs 
from  the  lamina  papyracea  a  thicker  but  hollow  bony 
ledge,  likewise  slightly  slanting  inward  from  the  vertical 


ETHMOID    CELLS.  II3 

plane — the  bulla  ethmoidalis.  Its  interior  cavity  has  an 
opening  behind.  Between  the  uncinate  process  and  the 
bulla  there  is  a  curved  cleft — the  hiatus  semilunaris. 
This  -cleft  is  the  entrance  into  a  funnel-shaped  space  of  a 
depth  variable  up  to  i  cm., — the  infundibulum, — at  the 
bottom  (external  side)  of  which  are  the  orifices  of  the 
frontal  and  the  maxillary  sinus.  This  space,  as  well  as 
all  the  recesses  to  be  described,  is  lined  by  the  nasal 
mucous  membrane,  which  passes  uninterruptedly  through 
the  orifices  into  the  different  sinuses,  but  in  these  spaces 
does  not  retain  the  thickness  and  the  venous  plexus 
which  it  possesses  in  the  nasal  cavity. 

Above  the  bulla  another  ledge  springs  from  the  lamina 
papyracea — the  middle  turbinal.  This  passes  inward  and 
then  curves  downward  like  a  cornice,  so  as  to  cover  com- 
pletely the  hiatus  semilunaris.  The  middle  turbinal  ex- 
tends beyond  the  lamina  papyracea  backward  and  some- 
what downward,  reaching  thus  underneath  the  inferior 
surface  of  the  sphenoid  body  up  to  the  rear  end  of  the 
nasal  passage. 

The  spaces  between  the  uncinate  process  and  bulla  and 
middle  turbinal  form  the  anterior  ethmoid  cells.  These 
recesses  open  thus  into  the  middle  meatus  of  the  nose 
underneath  and  external  to  the  middle  turbinal. 

Above  the  middle  turbinal,  and  somewhat  back  of  it, 
another  ledge  arises  from  the  lamina  papyracea,  the 
superior  turbinal,  while  finally  and  uppermost  another 
bony  lamella  springs  from  the  horizontal  plate  of  the 
ethmoid — the  supreme  turbinal.  These  thin  bony  ledges 
all  curve  downward  with  edges  more  or  less  rolled,  form- 
ing the  upper  ethmoturbinal  processes.  The  spaces 
inclosed  between  them  are  the  posterior  ethmoid  cells., 
which  open  into  the  olfactory  fissure  between  the  middle 
turbinal  and  septum  (Fig.  38). 

The  architecture  of  the  ethmoid  cells  is  complicated 
by  the  variable  curvature  and  irregular  shape  of  the 
turbinal  ledges,  but  especially  by  incomplete  bony  or 
membranous  septa  subdividing  these  longitudinal  pass- 


114 


ANATOMY    OF   THE    NASAL   ACCESSORY    CAVITIES. 


ages  into  a  series  of  commuiiicatiug  cells  of  variable  size 
and  number.  These  cells  constitute  the  ethmoid  laby- 
rinth. All  these  spaces  are  lined  with  a  continuation  of 
the  nasal  mucous  membrane.     The  bony  frame  of  the 


Fig.  38. — Ethmoid  labyrinth  from  the  nasal  side,  with  demonstration  of  the 
main  lamellae:  s.f.  Frontal  sinus;  s.  sph,  sphenoid  sinus;  L^,  the  first  lamella, 
the  uncinate  process;  Z*,  the  second  lamella,  the  bulba  ethmoidalis;  h.s, 
hiatus  semilunaris ;  Z',  the  third  lamella,  the  main  lamella  of  the  middle  tur- 
binal ;  s.  e.  a,  anterior  ethmoid  cell ;  Z*,  the  fourth  lamella,  the  main  lamella 
of  the  superior  concha;  s.  e.p,  posterior  ethmoid  cells  (Hajek). 


middle  turbinal  broadens  in  its  anterior  part  by  becoming 
cancellated.  The  deeper  (periosteal)  layer  of  the  mucous 
membrane  dips  into  the  spaces  between  the  bone-plates 
and  assumes  a  medullary  structure  rich  in  fat-cells.     In 


ETHMOID    CELLS. 


"5 


some  instances  pneumatic  cells  extend  into  the  middle 
turbinal  process. 

The  number  and,  conversely,  the  size  of  the  indi- 
vidual ethmoid  cells  vary  considerably.  In  rare  in- 
stances there  are  only  a  few  large  spaces.  The  relation 
in  size  of  anterior  to  posterior  cells  is  also  variable  and 
depends  on  the  site  of  the  middle  turbinal,  which  divides 
the   two  sets  of  cells  from    each   other.     The  ethmoid 


Fig.  39. — Large  frontal  sinus ;  the  ethmoid  labyrinth  exposed  through  the 
lamina  papyracea :  s.  f.  Frontal  sinus  ;y!  /,  lachrymal  fossa;  s.  m,  maxillary 
sinus;  c.  e.  a,  anterior  ethmoid  cells  (4);  c.  e.p,  posterior  ethmoid  cells  (4) ; 
d.e,  nasal  orifices  of  ethmoid  cells  (Hajek). 

bulla  is  occasionally  enlarged  and  expanded,  sometimes 
to  an  extent  to  become  visible  on  anterior  inspection.  Its 
enlargement  is  apt  to  cause  one  or  more  of  the  foremost 
cellular  spaces  to  intrude  into  the  frontal  sinus.  On  the 
other  hand,  the  rear  cell  of  the  posterior  set  may  also 
intrude  into  the  sphenoid  sinus  (Fig.   39). 

The  orifices  of  the  anterior  ethmoid  cells,  variable  in 
number  on  account  of  the  variability  in  the  size  and 


ii6 


ANATOMY    OF   THE    NASAL   ACCESSORY    CAVITIES. 


intercommunications  of  the  cells,  open  usually  between 
bulla  and  middle  turbinal.  The  posterior  cells  present 
small  openings  along  the  external  wall  of  the  superior 

nasal  meatus. 

FRONTAL  SINUS. 

44.  The  frontal  sinus  is  an  irregularly  shaped  cavity 
in  the  frontal  bone  above  and  between  the  orbits.  It  is 
variable  in  size  and  extent,  usually  larger  in  the  male 
than  in  the  female  (Figs.  40  and  41).  Scarcely  developed 
at  birth,  it  grows  slowly  until  puberty,  when  it  is  only 
about  the  size  of  a  pea,  after  which  period  it  rapidly  gains 


Fig.  40. — Frontal  bone,  the  external  plate  removed  to  show  the  frontal 
sinus:  u.  Lower  wall,  A,  posterior  wall,  of  frontal  sinus;  s,  frontal  septum; 
p./,  frontal  orifice;  JS,  bulba  frontalis  (Zuckerkandl). 

its  full  development.  The  two  sinuses  are  separated  by  a 
median  partition  occasionally  curved  and  asymmetric. 
The  vertical  height  close  to  the  septum  is  between  28 
and  40  mm.  The  anteroposterior  depth  is  determined  to 
some  extent  by  the  prominence  of  the  brow.  It  may  ex- 
tend backward  as  far  as  the  middle  of  the  orbit  or  even 
beyond.  More  variable  even  is  the  transverse  width  of 
the  two  spaces,  which  oscillates  between  20  and  75  mm. 
Sometimes  one  or  both  cavities  are  rudimentary  or  even 
obliterated.  The  anterior  wall  is  generally  quite  thick. 
The  floor  formed  by  the  upper,  and  to  some  extent  by 


SPHENOID    SINUS, 


117 


the  inner,  orbital  wall  is  the  thinnest  boundary.  Occa- 
sionally a  sinus  is  incompletely  subdivided  by  bony  par- 
titions. At  the  lowest  part  of  the  floor  is  the  orifice 
of  the  nasofrontal  duct,  a  short,  funnel-shaped  opening. 
The  distance  between  the  orifices  of  the  two  frontal  si- 
nuses is  determined  by  the  width  of  the  ethmoid  bone. 


Fig.  41. — Sagittal  section  through  frontal  sinus  :  S,  Frontal  sinus ;  6,  frontal 
bulla;  s,  sinus  within  frontal  bulla;  £,  bulla  ethmoidalis;  P,  uncinate  process* 
//,  sinus  between  anterior  insertion  of  the  middle  turbinal  and  the  uncinate 
process  (Zuckerkandi). 

The  nasal  entrance  is  usually  at  the  anterior  end  of  the 
hiatus  semilunaris,  between  the  uncinate  process  and 
bulla  of  the  ethmoid,  sometimes,  however,  anterior  to  it, 
but  always  underneath  and  hidden  by  the  front  end  of 
the  middle  turbinal.  Occasionally  an  anterior  ethmoid 
cell  protrudes  into  a  frontal  sinus. 


SPHENOID   SINUS. 

45.  The  sphenoid  sinus  is  the  cavity  in  the  interior  of 
the  body  of  the  sphenoid  bone,  separated  by  a  median  and 


ii8 


ANATOMY   OF    THE    NASAL    ACCESSORY   CAVITIES. 


not  always  symmetric  wall  into  two  non-communicating 
spaces  (Fig.  42).  This  sinus  varies  in  height  from  13  to 
27  mm. ;  in  length,  from  10  to  28  mm. ;  and  in  width, 
each  from  10  to  over  25  mm.  (by  extension  into  the  lesser 
wing  of  the  sphenoid  bone).  It  is  rudimentary  during 
early  childhood.     Bony  partitions  sometimes  subdivide 


Fig.  42. — External  wall  of  left  nasal  passage  :  b,  Bulla  ethmoidalis ;  /,  unci- 
nate process ;  t,  lachrymal  bone ;  W,  superior  vault  of  the  hiatus  projecting 
toward  the  frontal  sinus;  O,  nasal  orifice  of  frontal  sinus;  O.f,  passage  into 
frontal  sinus  partially  opened;  m,  middle  lurbinal;  m' ,  middle  ethmoturbinal ; 
O,  superior  ethmoturbinal ;  a,  fissure  between  bulla  ethmoidalis  and  middle  tur- 
binal  leading  info  a  sinus  of  the  orbital  part  of  the  frontal  bone  ;  a',  cell  between 
the  middle  turbinal  and  the  anterior  sphenoid  surface,  without  partition  between 
the  two  spaces  (Zuckerkandl). 


it  into  several  spaces.  The  superior  wall,  usually  solid, 
is  sometimes  imperfect,  which  may  bring  its  mucous 
lining  in  contiguity  with  the  dura  mater,  thus  en- 
dangering the  optic  nerves  above  it  in  case  of  disease. 
The  lateral  walls  are  largely  within  the  intracranial 
cavity.  Adjoining  them  (above)  are  the  internal  carotid 
artery  and  the  cavernous  sinus.    The  inferior  (nasal  wall) 


SPHENOID    SINUS. 


119 


is  the  thinnest.  The  orifice  of  each  sinus  is  situated  in  its 
anterior  wall  near  the  roof,  in  the  space  between  the  sep- 
tum and  the  nasal  surface  of  the  ethmoid  labyrinth. 
This  opening,  of  good  size  in  the  skeleton,  is  narrowed 
by  the  mucous  membrane  and  is  sometimes  reduced  to  a 
mere  slit.     It  can  be  reached  directly  by  a  slender  instru- 


FlG.  43. — Horizontal  section  through  the  human  frontal,  ethmoid,  and 
sphenoid  bones :  S.f,  Frontal  sinus ;  L.  <•,  lamina  cribrosa;  C,  ethmoid  cells; 
O.  sph,  sphenoid  orifice;  S.  ^.^,  sphenoid  sinus  (Zuckerkandl). 


ment  inserted  through  the  olfactory  fissure.  The  dis- 
tance from  this  orifice  to  the  pyriform  aperture  of  the 
nose  has  been  found  to  vary  from  60  mm.  to  82  mm.  in 
the  living  (Fig.    43). 

Embryologically  the  sphenoid  sinus  is  originally  the 
upper  rear  portion  of  the  olfactory  fissure.     The  upper 


120  ANATOMY    OF    THE    NASAL    ACCESSORY    CAVITIES, 

rear  ethmoturbinal  (cartilaginous)  lamella  of  each  side 
changes  during  its  ossification  into  a  closed  bony  capsule, 
the  sphenoid  concha  or  ossicle  of  Bertinus.  The  inclosed 
space  is  the  sphenoid  sinus,  which  is  thus  separated  from 
the  nasal  chamber  at  birth,  though  as  yet  very  small. 
The  body  of  the  sphenoid  bone  behind  it  is  small  and 
solid.  The  sphenoid  rostrum,  however,  is  an  extended 
partition  and  separates  the  capsules  of  the  two  sinuses. 

About  the  fourth  year  the  ossicles  of  Bertinus  begin  to 
atrophy,  and  the  anterior  surface  of  the  sphenoid  body 
curves  around  them  by  its  growth  on  all  sides  except 
the  median.  About  the  tenth  to  the  twelfth  year  the 
sphenoid  conchse  have  dwindled  down  to  small  triangu- 
lar plates  which,  by  their  coalescence  with  the  growing 
sphenoid  walls,  now  form  part  of  the  anterior  wall  of  the 
sinus,  while  all  the  other  sides  are  now  supplied  by  the 
sphenoid  body  itself.  The  rostrum  has  become  the  par- 
tition wall  between  the  two  sinuses.  From  this  time 
until  puberty  the  sinus  completes  its  growth  at  a  more 
rapid  rate. 

MAXILLARY  SINUS. 

46.  The  maxillary  sinus  or  antrum  of  High  more  is  an 
irregularly  shaped  cavity  in  the  interior  of  the  superior 
maxillary  bone,  which  can  be  approximately  compared 
to  a  three-sided  pyramid  with  base  upward  (the  orbital 
floor),  an  external  or  facial,  an  internal  or  nasal,  and  a 
posterior  side  (Fig.  44).  It  is  scarcely  developed  at 
birth,  and  does  not  reach  its  final  size  until  after  the 
second  dentition.  When  well  formed  in  the  adult,  its 
different  dimensions  range  between  20  and  35  mm.  But 
this  cavity  is  not  rarely  diminished  in  size  in  one  or  the 
other  direction  by  absorption  of  the  cancellated  bone 
tissue  in  the  alveolar  process  or  by  the  sinking-in  of  the 
facial  wall,  or  at  least  its  thinnest  part, — the  canine  fossa, 
— or  by  the  bulging  of  the  nasal  wall  toward  the  sinus. 
x\ll  these  conditions  may  coexist  and,  if  combined  with 
diffuse    thickening    of    the    bony   walls,    may    in    rare 


MAXILLARY    SINUS. 


121 


instances  almost  obliterate  the  sinus.  The  encroachment 
upon  the  cavity  by  any  considerable  depression  of  the 
facial  wall  reveals  itself  in  the  architecture  of  the  face, 
while  unusual  width  of  a  nasal  meatus  also  suggests 
stenosis  of  the  maxillary  sinus.  The  two  cavities  are 
not  rarely  asymmetric  (Fig.  45).     On    the    other  hand, 


Fig.  44. — Right  superior  maxilla ;  antrum  opened  from  the  external  side : 
O.  tn  (large),  maxillaiy  orifice ;  O.  ni.  a,  accessory  maxillary  orifice ;  f,  unci- 
nate process  (Zuckerkandl). 


the  space  is  often  enlarged  by  the  formation  of  niches  or 
recesses  in  the  solid  bone,  leading  to  the  formation  of  an 
alveolar — palatal — infra-orbital  or  molar  sinus,  while  in 
other  instances  the  cell  in  the  orbital  process  of  the 
palate  bone  may  constitute  a  posterior  niche  connected 
with  the  maxillary  sinus.  These  recesses  are  sometimes 
spaced  off  by  incomplete  bony  partitions.     Occasionally 


122 


ANATOMY    OF    THE    NASAL    ACCESSORY    CAVITIES. 


more  or  less  complete  bony  septa,  vertical  or  horizontal, 
divide  the  entire  sinus  into  two  separate  chambers,  each 
communicating  with  the  nose. 

The  floor  of  the  antrum,  formed  by  the  junction  of  the 
external  and  posterior  walls,  varies  in  width  in  different 
subjects,  and  is  often  reticulated  by  the  prominences  cor- 
responding to  the  teeth  beneath  the  floor.  According  to 
the  degree  of  absorption  of  the  cancellated   tissue,   the 


Fig.  45. — Asymmetry  of  the  two  maxillary  sinuses.  On  the  right  side,  at  a, 
a  deep  alveolar  recess,  while  on  the  left  side  the  alveolar  process,  b,  extends 
upward  (Zuckerkandl). 

roots  of  the  teeth  may  project  into  the  cavity  or  be 
separated  from  it  by  a  thick  alveolar  process.  The 
number  of  teeth  below  (or  in)  the  floor  of  the  antrum 
varies  with  the  development  of  the  alveolar  and  palatal 
niches.  Zuckerkandl  found  in  26  skulls  that  the  sinus 
reached  from  the  last  molar  to  the  first  molar  6  times,  to 
the  second  bicuspid  3  times,  to  the  first  bicuspid  13 
times,  to  the  canine  teeth  4  times.  The  infra-orbital 
canal,  containing  the  infra-orbital  nerve,  which  passes 
along  the  roof  of  the  antrum,  is  partly  deficient  in  some 
subjects,  leaving  the  nerve  exposed. 


MAXILLARY    SINUS. 


123 


The  opening  between  the  nose  and  sinus  is  in  the 
upper  part  of  the  nasal  wall  of  the  antrum,  close  to  the 
roof  or  orbital  wall  of  the  sinus  (see  Fig.  37).  It  is 
usually  oblong,  its  height  ranging  between  2  and  5  mm., 
and  its  length  between  3  and  10  mm.  But  this  opening 
leads  only  indirectly  into  the  nose  through  the  space 
called  the  infundibulum.  The  large  aperture  found  in 
the  upper  half  of  the  nasal  wall  of  the  macerated  max- 


FlG.  46. — R,  Superior  maxilla,  nasal  surface,  the  inferior  concha  partly  re-' 
sected  in  order  to  show  the  maxillary  process :  P.  m,  Maxillary  process  of  the 
turbinated  bone ;  P.  e,  ethmoid  process  of  the  turbinated  bone ;  P.  I,  lachrymal 
process  of  the  turbinated  bone;  C.  t,  turbinal  crest  of  the  palate  bone;  C.  e, 
ethmoid  crest  of  the  palate  bone ;  C.  e' ,  ethmoid  crest  .of  the  maxillary  bone 
(Zuckerkandl). 


illary  bone  is  narrowed  by  the  articulation  below  with 
the  maxillary  process  of  the  inferior  turbinated  and  the 
uncinate  process,  posteriorly  with  the  vertical  lamella  of 
the  palatal  bone,  and  above  with  the  hollow  process  of 
the  ethmoid — the  bulla  ethmoidalis  (Fig.  46).  The  latter 
forms  a  cornice  slanting  backward  and  somewhat  down- 
ward on  the  nasal  side  of  the  sinus  wall.  The  uncinate 
process  of  the  ethmoid  bone,  shaped  like  a  sickle,  begins 


124  ANATOMY    OF   THE    NASAL    ACCESSORY    CAVITIES, 

in  front  and  below  the  bulla,  and,  passing  backward  and 
somewhat  downward,  crosses  the  bony  aperture  and 
divides  this  opening  into  an  anterior  (lower)  and  a  pos- 
terior (upper)  half.  The  spaces  between  the  uncinate 
process  and  the  rim  of  the  bony  opening  are  closed  by 
mucous  membrane  and  constitute  the  nasal  fontanels 
of  the  antrum,  usually  containing  a  few  delicate  bony 
bridges.  Near  the  center  of  the  upper  or  posterior  fon- 
tanel, between  the  uncinate  process  and  bulla,  is  the 
orifice  of  the  maxillary  sinus.  The  cornice-like  project- 
ing bulla  and  the  uncinate  process  inclose  between  them 
a  semilunar  slit,  a  curved  recess  slanting  backward  and 
downward  like  the  processes  which  surround  it — of  a 
width  of  from  2  to  6  mm,  and  a  length  of  from  20  to  30 
mm.  This  slit,  the  hiatus  semilunaris,  is  the  nasal  gate- 
way into  the  space  between  the  bulla  and  uncinate  proc- 
ess,— the  infundibulum, — in  the  external  wall  of  which 
the  actual  opening  into  the  sinus  is  found.  In  the  wider 
anterior  portion  of  the  infundibulum  there  is  usually  the 
orifice  of  the  frontal  sinus ;  sometimes,  however,  it  is  an- 
terior to  it.  The  aperture  of  the  maxillary  sinus  is  thus 
situated  unfavorably  for  the  escape  of  secretions,  and 
every  slight  swelling  of  the  mucous  lining  of  the  semi- 
lunar hiatus  or  of  the  infundibulum  may  shut  ofi"  the 
communication  between  the  nose  and  sinus.  As  the 
semilunar  slit  is  completely  covered  by  the  middle  tur- 
binal,  it  is  invisible  during  life.  It  is  hence  difficult  and 
often  impossible  to  enter  it  with  instruments.  A  second 
accessory  maxillary  aperture  is  found  in  about  10 -per 
cent,  of  subjects  in  either  the  upper  or  the  lower  fonta- 
nel, but  is  usually  smaller  than  the  principal  orifice. 


CHAPTER  VII. 
DISEASES  OF  THE  MAXILLARY  SINUS. 

ACUTE  MAXILLARY  SINUITIS. 

47.  Acute  inflammation  of  the  maxillary  sinus  is  clin- 
ically an  occurrence  of  but  moderate  frequency,  and  not 
nearly  so  common  as  the  findings  of  fresh  lesions  at 
autopsies.  The  clinical  picture  is,  however,  well  defined 
and  not  dijEficult  to  recognize.  It  occurs  either  as  the 
sequel  of  an  acute  nasal  catarrh  or  an  influenza  rhinitis, 
or  sometimes  apparently  primarily.  In  other  less  com- 
mon instances  the  infection  proceeds  from  diseased  teeth. 
In  rare  instances  the  disease  is  brought  about  by  intra- 
nasal operations,  especially  cauterization.  Acute  onset 
of  moderate  fever,  with  general  malaise  for  a  few  days, 
disturbed  appetite,  and  bad  taste  usher  it  in.  As  a  rule, 
there  is  considerable  infra-orbital  pain,  sometimes  shoot- 
ing into  the  teeth,  and  often  supra-orbital  pain  and 
tenderness,  suggesting  involvement  of  the  frontal  sinus, 
which  is  not  present.  The  cheek  is  tender  to  touch, 
sometimes  slightly  edematous. 

The  acute  disease  is  usually  one-sided.  Free  discharge 
of  pus  from  one  side  of  the  nose  occurs  within  the  second 
day.  Sometimes  this  is  offensive  from  the  start.  Even 
if  the  pus  is  bland,  the  patient  usually  complains  of  a 
subjective  bad  smell. 

The  acute  symptoms  begin  to  subside  in  the  course  of 
about  a  week.  In  favorable  cases  the  disease  heals  spon- 
taneously in  from  three  to  six  weeks.  It  is  doubtful 
whether  a  spontaneous  cure  ever  occurs  in  cases  of  den- 
tal origin.  The  liability  to  become  chronic  is  increased 
by  the  coincidence  of  intranasal  lesions  causing  stenosis. 

The  diagnosis,  which  is  strongly  suggested  by  the  sub- 

125 


126  DISEASES    OF    THE    MAXILLARY    SIXUS. 

jective  symptoms,  is  confirmed  by  the  appearance  of  pus 
issuing  from  the  middle  nasal  meatus.  It  may  be  verified 
by  translumination  (see  %  49).  An  exploratory^  puncture 
is  scarcely  ever  needed  for  diagnostic  purposes. 

The  treatment  demands  physical  rest  during  the  acute 
stage.  Neuralgic  pain  can  be  suppressed  by  antipyrin  or 
phenacetin,  and,  if  these  fail  to  give  permanent  relief, 
quinin,  0.4  to  0.6  gm.,  taken  once  or  twice  daily,  in 
soft  capsules,  will  usually  succeed.  The  cure  is  facili- 
tated by  all  measures  favoring  drainage,  such  as  the 
douche,  the  use  of  sprays,  and  applications  of  cocain  or 
suprarenal  solution  in  the  middle  nasal  meatus.  As 
soon  as  the  nasal  tenderness  has  subsided  an  attempt 
may  be  made  to  inject  salt  solution  through  the  natural 
maxillary  opening  (see  T[  49).  If  this  is  successful,  an 
exploratory  puncture  may  be  deferred  as  long  as  there  is 
a  history  of  steady  improvement  under  the  less  active 
treatment.  If,  however,  a  series  of  days  brings  no  decided 
improvement,  irrigation  may  be  practised  through  an 
exploratory  puncture,  and,  if  necessary,  repeated  a  few 
times.  Chronicity  is  sometimes  due  to  irritation  by 
inspissated  pus,  which  can  be  removed  by  a  single  wash- 
ing out.  The  details  of  the  surgical  technic  will  be 
described  under  the  head  of  Chronic  Inflammation.  In 
cases  of  dental  origin  it  is  always  necessary  to  extract 
the  offending  tooth,  and  generally  best  to  puncture 
through  the  socket,   with  subsequent  irrigation. 

CHRONIC  INFLAMMATION   OF  THE  MAXILLARY  SINUS. 

48.  Symptoms. — Chronic  suppuration  of  the  maxillary 
sinus  (empyema  of  the  antrum  of  Highmore)  is  the  most 
frequent  cause  of  one-sided  purulent  discharge  from  the 
nose.  In  a  small  proportion  of  cases  the  disease  is  bilateral. 
The  history  is  often  vague.  A  few  cases  begin  acutely, 
especially  those  due  to  carious  teeth.  But  even  the  dental 
cases  may  be  of  insidious  onset.  While  most  acute  in- 
flammations, except  those  of  dental  origin,  heal  spon- 
taneously,  chronicity  may  be  due  to  preexisting  nasal 


CHRONIC    INFLAMMATION    OF    THE    MAXILLARY    SINUS.     12/ 

stenosis,  to  imperfect  drainage  on  account  of  a  small  or 
swollen  orifice,  or  to  poor  health  in  general.  In  many 
instances  no  acute  history  can  be  ascertained,  and  the 
lesion  probably  started  in  a  subacute  manner  during  the 
course  of  some  infectious  disease.  Traumatism  plays  a 
very  small  role.  Occasionally  foreign  bodies  (snuff,  vom- 
ited material)  enter  through  the  natural  opening.  More 
often  foreign  bodies  get  in  through  the  surgeon's  fault 
in  the  extraction  of  teeth  or  through  exploratory  open- 
ings made  for  acute  disease  and  not  properly  guarded. 
Sometimes  infection  results  from  an  intranasal  opera- 
tion, especially  cauterization. 

Chronic  maxillary  disease  may  remain  latent  for  an 
indefinite  period  of  time  in  some  instances.  Its  only 
constant  symptom  is  purulent  discharge.  This  is  some- 
times so  slight  as  to  escape  the  patient's  attention,  or, 
guided  by  the  shape  of  the  nasal  wall,  it  may  flow  into 
the  pharynx.  As  a  rule,  however,  it  is  the  pus  which 
annoys  the  patient.  Sometimes  the  discharge  is  very 
profuse.  It  is  more  often  foul  than  bland.  Occasionally 
the  discharge  is  but  moderately  offensive,  while  at  the 
operation  inspissated  pus  of  intense  fetor  is  met  with. 
Either  through  absorption  of  toxins  or  by  the  swallowing 
of  the  pus,  stomach  disturbances  and  interference  with 
nutrition  may  result.  A  bad  taste,  especially  in  the 
morning,   is  common. 

Nasal  obstruction  by  reason  of  turgescence  becomes 
annoying  in  proportion  to  the  narrowness  of  the  nose. 
Even  in  the  one-sided  disease  the  stuffiness  is  more  or 
less  bilateral,  but,  of  course,  most  marked  on  the  narrow 
side.  Sometimes  there  is  pronounced  nasal  irritability, 
with  sneezing  fits.  Asthma  is  an  uncommon  complica- 
tion. 

The  occurrence  of  pain  seems  to  depend  on  two  factors 
— viz.,  interference  with  drainage  by  reason  of  hyper- 
trophy around  the  hiatus  semilunaris,  and  a  neuropathic 
tendency.  There  may  be  headache,  but  more  often  infra- 
orbital neuralgia  or  pain  shooting  into  the  teeth  is  com- 


128  DISEASES    OF    THE    MAXILLARY    SINUS. 

plained  of,  sometimes  in  periodically  recurring  attacks. 
One-sided  disease  produces  one-sided  pain.  Tenderness 
of  the  cheek  is  not  always  marked. 

While  the  disease  may  be  combined  accidentally  with 
any  form  of  nasal  lesion,  the  intranasal  affection  most 
likely  to  be  associated  with  it  is  polypoid  hypertrophy 
around  the  hiatus  semilunaris.  This  may  not  be  visible 
until  the  front  end  of  the  middle  turbinal  is  amputated. 
It  can,  however,  be  felt  by  the  probe.  Persistent  profuse 
discharge  generally  leads  to  chronic  rhinitis  and  pharyn- 
gitis, sometimes  laryngitis.  While  the  ear  is  menaced 
only  indirectly  by  secondary  nasal  lesions,  empyema  of 
the  maxillary  sinus  occasionally  leads  to  eye  complica- 
tions, such  as  affections  of  the  tear-passages,  persistent 
and  recurring  iritis,  and  circumscribed  forms  of  chorio- 
retinitis. 

Suppurative  disease  of  the  maxillary  sinus  causes  no 
external  signs,  especially  no  distention  of  the  sinus  walls. 
When  the  latter  occurs,  it  is  always  due  to  the  presence 
of  cysts. 

The  lesions,  as  observed  at  autopsies  and  after  opera- 
tions, are  variable.  During  acute  sinuitis  inflammatory 
edema  is  commonly  found.  In  chronic  cases  this  mav 
also  persist,  but  oftener  an  actual  hypertrophy  of  the 
mucous  lining  is  found,  characterized  either  by  intense 
round-cell  infiltration  or  later  on  by  fibrillary  sclerosis. 
The  epithelium  is  mostly  intact,  but  the  surface  is  uneven, 
often  warty.  Polypi  are  not  often  seen.  Pigmentary 
accumulations  are  common  as  the  result  of  hemorrhages. 
Cysts  due  to  dilatation  of  glands  or  to  circumscribed  inter- 
stitial edema  are  quite  common.  There  may  be  granula- 
tion tissue  in  spots  devoid  of  epithelium,  usually  indi- 
cative of  lesions  in  the  bony  wall. 

As  the  deeper  layer  of  the  mucous  membrane  consti- 
tutes the  periosteum,  the  bony  walls  are  apt  to  become 
involved  in  severe  instances.  The  most  frequent  lesions 
are  osteophytes  like  stalactites  on  the  wall,  sometimes 
even  detached  and  loose.     Much  less  common,  but  more 


CHRONIC    INFLAMMATION    OF    THE    MAXILLARY   SINUS.    1 29 

serious,  is  caries  of  the  bone,  which  in  rare  instances  may 
lead  to  perforation.  Caries  cannot  be  recognized  with 
certainty  by  the  use  of  the  probe  alone,  on  account  of  the 
roughness  of  the  osteophytic  surface. 

49.  The  diagnosis  is  not  always  easy  and  may  require 
repeated  examinations.  If  pus  is  seen  issuing  from  un- 
derneath the  middle  turbinal,  it  should  be  removed  by 
mopping.  A  rapid  reappearance  of  pus  indicates  that  it 
comes  from  some  reservoir  opening  in  that  region,  which 
may  be  either  the  frontal  sinus,  the  anterior  ethmoid  cells, 
or  the  maxillary  sinus.  The  latter  is  the  most  frequent 
source.  On  account  of  the  location  of  its  orifice  next  to 
its  roof,  its  contents  do  not  escape  during  the  erect  posture 
except  by  overflow.  If  the  head  be  turned  so  as  to  bring 
the  orifice  to  the  lowest  level,  a  more  rapid  escape  takes 
place,  unless  the  fluid  is  very  viscid  or  has  been  emptied 
just  previously.  Exploration  of  the  orifice  with  a  probe 
is  possible  only  in  a  minority  of  instances.  The  jDrobe 
should  be  bent  at  nearly  right  angles  about  5  mm.  from 
the  tip.  The  middle  meatus  is  cocainized,  and  by  very 
gentle  manipulation  the  probe  is  pushed  through  the 
opening  in  the  hiatus  semilunaris,  or,  to  better  advantage 
even,  through  the  accessory  orifice,  if  one  is  found  poste- 
rior and  a  little  below  the  hiatus.  If  pus  is  present,  it 
will  be  found  on  the  probe  and  along  its  track.  If  the 
probe  can  enter  the  orifice,  an  attempt  may  be  made  to 
irrigate  through  the  same  channel  with  a  slender  silver 
or  rubber  cannula  shaped  like  the  probe.  Before  this  is 
done  the  nose  must  be  cleansed  completely  by  means  of 
the  douche.  When  irrigation  through  the  orifice  brings 
forth  pus,  the  diagnosis  is  definite.  The  finding  of  pus 
in  the  antrum  does  not  exclude  purulent  disease  of  the 
ethmoid  cells,  which  may  or  may  not  be  present  as  a 
complication. 

Translumination  is  a  valuable  but  not  infallible  diagnos- 
tic method.  A  miniature  electric  lamp  of  from  4  to  8 
candle-power,  mounted  in  a  metal  or  rubber  hood  open 
on  one  side,  is  placed  in  the  mouth,  and  the  lips  are 
9 


130  DISEASES    OF   THE    MAXILLARY    SINUS. 

firmly  closed.  Any  dental  plate  worn  by  the  patient 
must  previously  be  removed.  The  room  must  be  abso- 
lutely dark,  or  a  hood  of  opaque  cloth  may  be  placed 
over  the  heads  of  patient  and  examiner.  When  the  cur- 
rent is  turned  on,  a  red  glow  is  seen  through  the  normal 
cheek  and  extending  laterally  in' the  shape  of  a  butterfly's 
wing  underneath  the  lower  rim  of  the  orbit.  The  two 
normal  sides  are  generally  symmetric.  If,  however,  the 
maxillary  sinus  of  one  side  is  rudimentary  and  the  cheek 
bone  indented,  the  corresponding  side  may  be  darker 
than  the  other.  When  pus  is  present,  the  darkness  of 
the  affected  side  is  unmistakable.  Decided  absence  of 
translucency  is  a  positive  indication  of  maxillary  disease. 
Either  one-sided  or  double-sided  sinuitis  will  rarely  es- 
cape detection,  but  a  moderate  darkening  may  simply  be 
due  to  denser  structure  of  the  bony  walls.  A  diseased 
antrum,  containing  at  the  time  but  little  pus  or  only  a 
thin  secretion,  may  give  a  doubtful  indication.  The 
diminished  translucency  in  antrum  diseases  is,  however, 
not  due  merely  to  the  presence  of  pus,  but  also  to  changes 
in  the  mucous  membrane — for,  in  pronounced  instances, 
the  red  glow  does  not  return  at  once  after  evacuation  of 
the  antrum. 

When  all  other  indications  fail,  the  diagnosis  can  be 
established  by  an  exploratory  puncture.  After  cleansing 
the  nose  with  a  douche,  a  stout  hollow  needle  is  thrust 
through  the  external  nasal  wall  into  the  sinus,  2.^  to 
3  cm.  behind  the  front  end  of  the  inferior  turbinal. 
Above  the  inferior  turbinal  the  nasal  wall  is  membranous 
or  contains  but  a  thin  lamella  of  bone.  It  is  hence 
easily  perforated ;  but  if  the  nasal  passage  is  very  wide 
and  the  antrum  small,  care  must  be  taken  not  to  pene- 
trate through  the  cavity  into  the  orbital  wall  of  the 
sinus.  On  the  other  hand,  below  the  inferior  turbinal 
the  bony  wall  is  so  thick  that  much  force  is  required,  an'd 
some  pain  may  be  felt  in  spite  of  cocain.  There  is, 
however,  scarcely  any  possibility  of  not  striking  the 
antrum  if  the  needle  is  held  as  nearly  transversely  as  the 


CHRONIC    INFLAMMATION    OF    THE    MAXILLARY   SINUS.    I3I 

space  permits  and  is  pointed  upward.  If  it  enters  the 
nasal  wall  too  far  in  front,  it  may  penetrate  through  the 
anterior  maxillary  wall,  and  the  subsequent  injection 
may  cause  swelling  and  possibly  infection  of  the  cheek. 
When  the  socket  of  the  second  bicuspid  or  first  or  second 
molar  tooth  is  available,  the  antrum  can  easily  be  reached 
by  means  of  a  small  drill.  An  effort  should  first  be  made 
to  blow  out  the  secretion  by  means  of  an  air-bulb,  since 
a  serous  fluid  would  escape  detection  when  mixed  with 
water.  Subsequently  a  stream  of  tepid  sterile  salt  solu- 
tion may  be  forced  through  the  needle,  and  the  escaping 
fluid  caught  as  it  flows  from  the  nose. 

50.  Treatment. — It  is  doubtful  whether  a  chronic  maxil- 
lary empyema  ever  heals  without  evacuation  even  under 
favorable  circumstances.  The  treatment,  therefore,  con- 
sists in  the  evacuation  of  the  fluid.  This  may  be  at- 
tempted by  irrigation  through  the  natural  or  accessory 
orifice  by  means  of  a  slender  silver  or  rubber  cannula  bent 
near  its  tip.  This  procedure,  only  occasionally  possible, 
is  unreliable  as  to  permanent  effect.  It  is  facilitated  by 
the  removal  of  the  front  end  of  the  middle  turbinal  in 
case  this  operation  is  indicated  by  reason  of  hypertrophies 
in  the  middle  meatus.  If  any  of  the  upper  teeth  back  of 
the  incisors  are  diseased  at  their  roots,  tender  to  pressure 
or  to  heat  or  cold,  their  extraction  is  indispensable. 

The  easiest  operation  for  draining  the  antrum  is 
through  the  socket  of  an  extracted  tooth,  preferably  the 
first  molar,  or,  if  need  be,  the  second  molar  or  second 
bicuspid.  It  is  rarely  desirable  to  sacrifice  a  healthy 
tooth.  A  narrow  orifice  can  be  drilled  on  the  internal 
side,  between  the  two  molars  or  first  molar  and  bicuspid, 
but  this  opening  has  its  drawbacks  and  is  usually  too 
small.  The  drilling  can  best  be  done  with  a  drill 
attached  to  a  dental  motor.  A  conic  hand  drill  can  be 
used  (Fig.  47)  instead,  but  is  more  awkward  where  the 
alveolar  process  is  thick.  The  hole  should  be  at  least  5 
mm.  wide.  Cocain  or  nirvanin  injected  under  the  gums 
secures  painlessness.     The  thickness  of  bone  varies  from 


132  DISEASES    OF    THE    MAXILLARY    SINUS. 

perhaps  2  to  8  or  10  mm.  When  the  facial  wall  of  the 
sinus  is  deeply  sunken  in,  there  is  a  small  possibility  of 
drilling  from  the  alveolar  socket  through  the  canine  fossa 
into  the  cheek.  Perforating  into  the  nose  can  happen 
only  when  the  instrument  is  held  too  slanting  and  when 
the  nasal  meatus  is  excessively  wide  at  the  exi^ense  of 
the  sinus.  After  irrigation  the  hole  may  be  plugged 
with  iodoform  gauze  for  a  day  or  two.  Later  a  rubber 
plug  or  cannula  should  be  fitted  by  a  dentist.  This  must 
be  guarded  from  slipping  in  by  a  thickened  inferior  edge, 
and  will  readily  stay  in  place  if  slightly  club-shaped  at 
its  upper  end.  If  the  plug  is  hollow,  irrigation  can  be 
practised  through  it  without  the  necessity  of  removing  it 
every  time.  Food  does  not  enter  through  a  small  open- 
ing.    Without  plug  the  fistula  would  close  rapidly  by 


Fig.  47. — Hand  drill  for  the  maxillary  antrum. 

granulations.  The  patient  learns  easily  to  irrigate  through 
the  opening,  using  warm  sterile  salt  or  boric  acid  solution 
in  a  rubber  bulb  syringe  with  pointed  nozzle.  There  is 
no  natural  drainage  through  the  opening,  as  the  fluid  is 
too  viscid,  and  the  opening  is  not  necessarily  at  the  low- 
est point  of  the  sinus. 

The  puncture  through  the  alveolar  process,  known  as 
Cowper's  operation,  gives  immediate  relief  from  all 
symptoms,  but  cures  only  a  fair  minority  of  cases,  espe- 
cially those  of  dental  origin.  If  the  secretion  does  not 
diminish  steadily  in  the  course  of  weeks,  and  has  not 
ceased  entirely  after  the  lapse  of  from  three  to  four 
months,  no  further  improvement  can  be  expected,  ex- 
cept from  a  more  radical  operation.  Comfort,  however, 
can  be  secured  as  long  as  the  opening  is  patent  and  irri- 


CHRONIC    INFLAMMATION    OF    THE    MAXILLARY    SINUS.    1 33 

gatioii  is  practised.  When  no  more  secretion  is  found, 
the  opening  should  be  maintained  about  two  weeks  for  a 
further  test  before  the  phig  or  cannula  is  withdrawn  per- 
manently. If  a  scanty  secretion  still  persists,  it  will 
become  noticeable  again  during  a  week  or  two  of  inter- 
mission. Upon  withdrawing  the  rubber  plug  the  open- 
ing shrinks  within  about  one  week  to  a  fine  fistula,  which 
then  closes  more  slowly.  If  a  foreign  body  gets  into  the 
sinus  through  the  opening,  the  suppuration  continues 
until  it  is  removed. 

51.  Drainage  into  the  inferior  meatus  of  the  nose  is 
preferred  by  some  operators  to  Cowper's  operation.  In 
several  recent  reports  by  German  and  American  observers 
this  operation  has  been  highly  praised,  although  most 
rhinologists  have  formerly  found  it  objectionable.  A 
stout  curved  trocar  (Fig.  48)  is  thrust  through  the  thick 


Fig.  48. — Curved  trocar  for  perforating  the  maxillary  sinus  through  the  nose. 

nasal  wall  of  the  sinus  underneath  the  inferior  turbinal, 
and  nearly  3  cm.  behind  its  front  end,  the  instrument 
pointing  slightly  upward.  In  spite  of  cocain  this  is  apt 
to  be  painful.  The  opening  has  not  so  much  tendency 
to  shrink  as  the  puncture  through  the  alveolar  socket. 
On  the  other  hand,  it  is  practically  impossible  to  fit  a 
cannula  into  it.  It  is  more  difficult  for  the  patient  and 
often  more  painful  to  learn  to  wash  out  the  sinus  through 
this  opening.  But  it  has  been  claimed  recently  that 
many  cases  heal  even  without  irrigation,  except  during 
the  first  few  days,  if  the  opening  is  only  kept  patent. 
Insufflations  of  boric  acid  or  iodoform  have  been  prac- 
tised with  good  results. 

52.  The  obstacle  to  a  permanent  cure  of  maxillary  em- 
pyema may  be  the  existence  of  polypi  or  granulations  in 
the  sinus,  or,  less  commonly,  caries  of  its  walls.     Cases 


134  DISEASES    OF    THE    MAXILLARY    SINUS. 

not  cured  by  irrigation  through  a  small  orifice  require 
removal  of  the  anterior  wall.  This  procedure,  known 
as  Kiister's  operation,  can  be  tolerated  under  cocain  or 
nirvanin  injection,  but  may  require  narcosis  in  the  case 
of  a  timid  person.  A  horizontal  incision  is  made  down 
to  the  bone  below  the  canine  fossa  from  the  canine  tooth 
to  the  second  molar.  At  its  front  and  rear  ends  the 
incision  is  curved  upward  in  order  to  form  a  flap.  The 
periosteum  is  detached  upward,  and  the  thin  anterior 
wall  of  the  sinus  perforated  either  with  a  large  trephine 
run  by  a  motor  or  with  a  chisel.  The  opening  is  enlarged 
with  bone  nippers  until  a  fair  view  can  be  had  of  the 
interior  of  the  sinus.  If  the  probe  or  inspection  reveals 
no  extensive  changes  in  the  interior,  the  operation  may 
be  considered  finished.  The  view  at  the  time  is,  however, 
often  hindered  by  bleeding.  A  tampon  of  iodoform  gauze 
is  then  inserted  for  a  couple  of  days.  After  that  time  the 
interior  can  be  inspected,  and  polypi  and  patches  of  gran- 
ulations can  be  removed  under  cocain  anesthesia.  A  rub- 
ber obturator  plate  is  then  to  be  fitted  by  a  dentist.  The 
patient  irrigates  several  times  daily,  and  the  cavity  is  in- 
spected from  time  to  time  in  order  to  treat  surgically 
any  hypertrophy  of  the  mucous  membrane  or  patches 
of  granulation.  The  healing  always  requires  a  number 
of  months.  A  large  opening  will  persist  without  harm 
for  a  long  period  or  indefinitely. 

When  inspection  shows  extensive  changes  in  the 
cavity  at  the  time  of  the  operation,  or  when  such  changes 
can  be  assumed  on  account  of  rebelliousness  to  previous 
treatment  through  a  former  opening,  a  more  radical 
operation  is  to  be  performed.  The  entire  anterior  bony 
wall  is  then  to  be  resected,  and,  after  thorough  curetting 
of  the  interior,  the  anterior  flap  of  periosteum  and  mucous 
membrane  is  pushed  into  the  cavity  after  loosening  it  by 
two  lateral  vertical  incisions.  It  is  then  made  to  cover 
the  denuded  walls  by  tamponing.  In  extreme  instances 
Boenninghaus  has  added  to  this  operation  the  removal  of 
the  nasal  wall  of  the  sinus  by  careful  chiseling  from  the 


CYSTS    IN    THE    MAXILLARY    SINUS.  1 35 

side  of  the  antrum.  He  thereupon  pushes  the  mucous 
membrane  into  the  sinus  from  the  nose,  and  thus  practi- 
cally covers  what  is  left  of  the  sinus  walls  with  healthy- 
mucous  lining  from  the  nose  and  from  the  gum.  As 
cicatrization  proceeds  very  slowly  over  the  denuded  sinus 
walls,  the  transplantation  of  Thiersch  grafts  has  been 
practised  to  advantage.  The  healing  requires  many 
months,  but  ultimately  an  entire  cessation  of  secretion 
can  be  obtained. 

A  similar  but  less  radical  operation  has  been  practised 
by  Caldwell  and  is  warmly  indorsed  by  Luc.  The  an- 
terior bony  wall  is  lifted  up  in  the  form  of  a  flap  with 
base  up  by  chiseling  and  finally  breaking  the  bone.  The 
cavity  is  inspected  and  treated,  and  a  counteropening  is 
made  into  the  nose.  The  diseased  lining  of  the  sinus 
is  thoroughly  destroyed  by  swabbing  with  a  saturated 
chlorid  of  zinc  solution.  After  a  gauze  drain  has  been 
placed  through  the  nasal  opening,  the  anterior  flap  is 
replaced  and  sutured. 

CYSTS  IN  THE  MAXILLARY  SINUS. 

53.  Autopsies  and  surgical  explorations  have  shown 
the  frequent  occurrence  of  cysts  in  the  maxillary  sinus, 
sometimes  with  very  little^  concomitant  disease  of  the 
mucous  membrane.  They  are  either  retention  cysts, 
originating  from  the  mucous  glands,  or  edematous  accu- 
mulations in  the  interior  of  polypoid  hypertrophies.  The* 
contents  are  usually  a  clear,  yellowish,  viscid  fluid  which 
coagulates  spontaneously.  Glandular  cysts  may  also  have 
purulent  contents  due  to  secondary  infection.  The  symp- 
toms due  to  cysts  are  vague.  Probably  no  annoyance  is 
caused  in  many  instances.  In  others  they  may  induce 
nasal  irritability.  Local  discomfort,  headaches,  and  ill- 
defined  neuralgic  pains  are  sometimes  produced  by  them, 
and  are  relieved  by  treatment.  If  not  accompanied  by 
empyema  or  not  purulent  in  themselves,  these  cysts 
cannot  be  recognized  with  certainty.  Translumination 
usually  shows  a  suspicious  reduction  of  translucency,  but 


136  DISEASES    OF   THE    MAXILLARY   SINUS. 

not  always.  On  puncturing  and  aspirating,  the  charac- 
teristic clotting  fluid  is  obtained.  If  cholesterin  crystals 
are  found,  it  indicates  a  retention  cyst.  Evacuation  re- 
lieves the  symptoms,  sometimes  permanently,  sometimes 
transiently.  When  the  contents  are  purulent,  a  rapid 
but  only  apparent  cure  results  from  a  single  irrigation, 
but  a  permanent  result  can  be  obtained  only  by  evulsion 
of  the  cyst-wall  through  a  sufficiently  large  opening. 

Of  an  entirely  different  nature  are  dental  or  follicular 
cysts.  They  are  made  up  of  a  thin  bony  capsule,  often 
containing  an  included  tooth.  The  fluid  is  turbid  and 
viscid  or  even  purulent.  They  are  of  slow  growth,  but 
ultimately  lead  to  distention  of  the  antrum  and  bulging 
of  one  or  more  of  its  walls.  Follicular  dental  cysts  and 
tumors  are  the  only  lesions  which  are  positively  known 
to  cause  distention  of  the  antrum  walls.  The  other 
symptoms  are  usually  vague.  The  treatment  consists  in 
removal  of  the  entire  capsule  with  chisel  and  bone  for- 
ceps through  an  opening  in  the  canine  fossa. 


CHAPTER  VIII. 

DISEASES   OF    THE    FRONTAL   SINUS,    ETHMOID 
CELLS,  AND   SPHENOID   SINUS. 

INFLAMMATION  OF  THE  FRONTAL  SINUS. 

54.  Acute  inflammation  of  the  frontal  sinus,  less 
common  than  acute  disease  of  the  maxillary  cavity,  is  a 
well-defined  clinical  occurrence.  During  a  coryza  or  after 
an  influenza  or  some  general  systemic  infectious  disease 
(typhoid  fever  or  erysipelas)  it  starts  with  slight  fever 
and  pain  over  the  brow,  the  latter  sometimes  very  severe. 
There  may  be  more  or  less  continuous  dull  browache, 
with  spells  of  sharp,  supra-orbital  neuralgia.  Often 
there  is  transient  edema  of  the  upper  eyelid.  There  is 
always  tenderness  to  touch  over  the  brow  and  on  the 
upper  wall  of  the  orbit.  The  disease  is  mostly  one- 
sided. Either  at  once  or  within  a  few  days  there  occurs 
a  profuse  purulent  discharge  from  that  side  of  the  nose, 
sometimes  with  relief  of  the  pain.  Of  course,  there  is 
some  nasal  stuffiness,  especially  if  there  is  a  complicat- 
ing diffuse  nasal  catarrh.  Acute  frontal  sinuitis  heals  in 
most  instances  within  from  two  to  three  weeks,  but 
without  adequate  treatment  an  unknown  proportion  of 
cases  become  chronic.  Even  after  apparent  cure,  occa- 
sional later  relapses  are  not  uncommon.  The  diagnosis, 
complications,  and  treatment  can  be  discussed  under  one 
heading  for  acute  and  chronic  disease. 

55.  Chronic  inflammation  of  the  frontal  sinus  is 
usually  the  prolongation  of  an  acute  attack.  In  other 
instances  it  begins  insidiously.  Its  occurrence  is  favored 
by  septum  deflection  and  hypertrophies  in  the  middle  nasal 
meatus,  the  latter  themselves  often  a  result  of  sinuitis. 
The  disease  is  sometimes  wholly  latent,  and  indicated  only 

137 


138  DISEASES    OF    THE    FRONTAL    SINUS. 

by  purulent  discharge.  Usually  subjective  symptoms  are 
added  whenever  an  acute  coryza  occurs.  In  most  in- 
stances more  or  less  suflfering  is  constantly  present.  This 
may  be  dull  or  sharp  frontal  headache,  usually  but  not  in- 
variably one-sided,  when  the  sinuitis  is  one-sided,  which 
is  the  more  common  occurrence.  More  characteristic 
is  supra-orbital  pain  in  attacks,  sometimes  of  remarkably 
punctual  periodicity.  Mental  irritability,  depression,  in- 
ability to  concentrate  the  attention,  more  rarely  dizzi- 
ness, may  be  complained  of  There  is  commonly  tender- 
ness over  the  brow  and  along  the  upper  wall  of  the  orbit. 
Occasionally  puffiness  of  the  upper  eyelid  is  seen. 

The  discharge  is  variable  in  amount,  and  is  sometimes 
retained  for  a  few  days  on  account  of  swelling  in  the  in- 
fundibulum.  When  temporarily  confined,  it  may  or  may 
not  cause  suffering,  which  may  be  suddenly  relieved  by 
the  reappearance  of  the  flow.  When  profuse,  the  flow  is 
fairly  continuous  during  the  erect  posture.  The  pus  is 
not  always  fetid,  rather  less  often  than  in  the  case  of 
maxillary  empyema.  The  mucous  membrane  around 
the  infundibulum  underneath  the  middle  turbinal  is 
mostly  swollen.  During  acute  sinuitis  this  swelling  is 
due  to  edema.  Later  on  polypoid  hypertrophy  of  the 
edges  of  the  hiatus  semilunaris  is  common.  When  there 
is  much  discharge,  chronic  rhinopharyngitis  usually 
results.  The  effects  of  pus-formation  and  swallowing 
of  pus  upon  digestion  and  nutrition  are  sometimes  seen 
when  the  suppuration  is  profuse. 

56.  Distention  of  the  walls  of  the  sinus,  especially 
bulging  of  the  thin  roof  of  the  orbit,  is  an  occasional 
symptom.  This  may  occur  very  slowly,  but  sometimes 
increases  rather  suddenly.  The  contents  in  this  case  are 
either  a  viscid,  slightly  turbid  mucus,  or  a  mucopurulent 
fluid,  but  usually  not  pure  pus.  In  some  instances  they 
have  been  found  bacteriologically  sterile.  While  it  has 
been  usually  assumed  that  the  accumulation  of  contents 
and  the  resulting  distention  depended  on  occlusion  of  the 
frontal  duct,  it  has  been  shown  recently  (Avellis)  that  at 


INFLAMMATION    OF   THE    FRONTAL    SINUS.  1 39 

least  in  some  of  these  cases  the  lesion  is  not  at  all  primary 
disease  of  the  frontal  sinus,  but  a  closed  mucocele  or 
empyema  of  an  ethmoid  cell  intruded  into  the  frontal 
sinus.  After  a  slow  growth  for  a  long  time,  such  a 
mucocele  may  finally  perforate  into  the  orbit. 

The  severest  cases  are  those  in  which  caries  of  the 
bony  walls  leads  to  perforation.  This  happens  rarely  in 
the  first  acute  attack,  more  commonly  during  a  later 
acute  exacerbation.  The  least  serious,  but  also  the  least 
frequent,  perforation  is  through  the  anterior  wall,  causing 
an  external  fistula.  More  common  and  more  important 
is  the  breaking-down  of  the  orbital  wall.  The  escape  of 
pus  into  the  orbit  may  lead  to  diffuse  phlegmonous  in- 
flammation and  may  even  cause  extension  into  the  cranial 
cavity,  with  fatal  results.  In  more  fortunate  cases  a  cir- 
cumscribed orbital  abscess  results,  which  may  open  at 
the  upper  inner  angle  of  the  orbit.  A  most  serious  but 
relatively  rare  accident  is  caries  of  the  posterior  wall  of 
the  sinus,  resulting  in  intracranial  disease  in  the  form 
of  a  subdural  or  cerebral  abscess  or  a  diffuse  meningitis  or 
thrombosis  of  the  longitudinal  sinus.  Further  diagnostic 
references  regarding  pyogenic  intracranial  affections  can 
be  found  in  the  chapter  on  Intracranial  Complications 
of  Middle-Bar  Disease. 

Frontal  sinuitis  causes  ocular  disturbances  quite  fre- 
quently, Asthenopic  discomfort  from  the  use  of  the  eyes 
and  insufficiency  of  convergence  are  frequent  functional 
disturbances.  Constriction  of  the  visual  field  has  been 
observed.  When  distention  of  the  orbital  wall  occurs, 
the  eyeball  is  displaced  laterally  and  its  mobility  may  be 
interfered  with.  The  most  serious  consequences  may 
ensue  in  case  of  perforation  into  the  orbit.  Thrombosis 
of  the  retinal  vein,  optic  neuritis,  and,  later  on,  atrophy 
have  been  observed,  although  such  complications  are 
rare, 

57.  The  lesions  in  the  frontal  sinus  are  principally  in- 
flammatory edema  during  the  acute  stage.  The  chronic 
form   depends   mostly   on   hypertrophy    of  the   mucous 


I40  DISEASES    OF    THE    FRONTAL   SINUS. 

membrane.  In  more  serious  cases  the  bony  walls  become 
involved,  at  first  by  the  formation  of  osteophytes,  but  in 
severe  infections  later  on  by  caries.  Perforation  seems 
to  occur  especially  along  the  channels  of  exit  of  the  sinus 
veins,  which  become  thrombosed.  When  the  walls  are 
gradually  distended,  the  process  is  one  of  bony  absorption 
on  the  inner  side,  with  deposition  of  fresh  bony  lamellae 
under  the  external  periosteum.  The  passage-way  from 
the  frontal  sinus  to  the  infundibulum  is  probably  never 
or  rarely  closed  permanently,  but  sometimes  temporarily 
occluded  at  its  nasal  end  by  swelling  or  hypertrophy  of 
the  mucous  membrane.  In  many  instances  inflammation 
of  the  frontal  sinus  is  complicated  by  suppuration  of  one 
or  more  of  the  most  anterior  of  the  ethmoid  cells,  which 
may  communicate  with  the  frontal  sinus  or  intrude  into  it. 
The  diagnosis  of  frontal  sinuitis  is  suggested  by  the 
external  signs,  when  present — viz.,  supra-orbital  neuralgia, 
tenderness,  especially  along  the  inner  upper  wall  of  the 
orbit,  edema  of  the  lid  or  bulging  of  the  sinus  wall. 
Pain  and  tenderness  without  other  symptoms  are  not 
sufficient  to  establish  the  diagnosis.  They  may  be  due 
to  true  supra-orbital  neuralgia  or  to  hysteria  with  some 
form  of  asthenopia.  Mucocele  without  discharge  can  be 
recognized  only  when  bulging  occurs.  The  discharge  of 
frontal  sinuitis  is  found  issuing  underneath  the  middle 
turbinal.  It  may  be  difficult  to  distinguish  between  in- 
flammation of  the  frontal  sinus,  the  ethmoid  cells,  and 
maxillary  antrum  by  means  of  the  nasal  symptoms. 
Maxillary  disease  must  first  be  excluded  by  translumi- 
nation  or  exploratory  puncture.  An  effort  should  be 
made  to  pass  a  probe  through  the  frontal  opening.  A 
flexible  silver  probe  is  bent  at  an  obtuse  angle  about  3 
cm.  from  its  end,  and  the  intranasal  part  may  be  slightly 
curved,  with  convexity  toward  the  external  side.  After 
cocainization  the  probe  is  to  search  underneath  the  front 
end  of  the  middle  turbinal  until  it  finds  a  passage  leading 
upward  and  forward.  When  it  has  been  pushed  in  by 
gentle  manipulation  to  the  extent  of  3  cm.,  it  is  either  in 


i 


INFLAMMATION    OF    THE    FRONTAL   SINUS.  I4I 

the  frontal  sinus  or  in  an  anterior  ethmoid  cell  intruded 
into  the  sinus,  which  cannot  be  distinguished  from  the 
sinus.  Probing  is  successful  only  in  a  minority  of  cases. 
When  the  removal  of  the  probe  is  followed  by  a  flow  of 
pus,  a  diagnosis  is  established.  In  doubtful  cases  syring- 
ing in  the  direction  of  the  probe  by  means  of  a  thin 
cannula  may  bring  forth  the  pus.  These  manipulations 
are  much  easier  after  the  front  end  of  the  middle  tur- 
binal  has  been  snared  off".  Repeated  examinations  may 
be  necessary  to  make  a  diagnosis.  It  is  sometimes  pos- 
.sible  to  force  out  the  pus  by  air  pressure  according  to  the 
Politzer  method  of  inflation — viz.,  by  blowing  into  the 
nose  with  a  rubber  bag  during  the  act  of  swallowing, 
while  the  other  nostril  is  firmly  closed  with  the  finger. 
Translumination  has  been  practised  by  means  of  two 
small  hooded  lamps  pressed  against  the  upper  inner 
recess  of  the  two  orbits.  In  the  absolutely  dark  room  or 
under  a  hood  a  red  glow  is  seen  over  the  area  of  the 
normal  frontal  sinus.  As  this  is  not  necessarily  sym- 
metric on  both  sides,  translumination  has  not  been  found 
trustworthy  by  most  observers. 

58.  The  treatment  of  acute  disease  requires  rest  and 
reduction  of  the  swelling  of  the  nasal  mucous  membrane. 
Cocain,  suprarenal  solution,  the  douche  (in  case  of  diffiise 
nasal  suppuration),  or  sprays  favor  drainage  from  the 
frontal  sinus.  The  neuralgia  can  be  checked  by  anti- 
pyrin  or  quinin  in  acute,  but  rarely  permanently  in 
chronic,  cases.  Pain  of  any  kind  is  relieved  by  drainage 
of  the  pus.  This  may  be  attempted  by  irrigation  through 
the  natural  orifice  if  feasible.  Decided  relief  can  some- 
times be  obtained  by  forcible  inflation  of  air  by  the 
Politzer  method.  When,  in  chronic  cases,  hypertrophies 
are  found  underneath  the  middle  turbinal,  it  is  best  to 
snare  off"  the  front  end  of  that  bony  process.  Polypoid 
growths  may  be  removed  by  the  snare  or  sometimes  even 
better  by  means  of  a  curet.  The  burner  should  never  be 
used  in  this  locality  for  fear  of  obliterating  any  of  the 
orifices  of  the   different   sinuses.      If  irrigation   of  the 


142  DISEASES    OF    THE    FRONTAL   SINUS. 

sinus  is  possible,  its  eflScacy  may  be  increased  by  using 
solutions  of  silver  nitrate,  2  to  5  per  cent,  in  strength, 
after  the  pus  has  changed  into  a  mucous  secretion.  So 
long  as  the  fluid  is  thick  and  yellow,  there  seems  to  be 
no  advantage  in  using  anything  but  salt  or  boric  acid 
solution.  Intranasal  methods  of  treatment  usually  suf- 
fice, even  when  there  is  some  distention  of  the  sinus 
walls.  A  number  of  weeks  or  even  some  months  may 
be  required,  however.  When  the  persistence  of  thick 
and  yellow  pus  indicates  graver  changes  in  the  mucous 
membrane  or  the  bony  walls  of  the  sinus,  or  when  alarm- 
ing symptoms  in  the  form  of  uncontrollable  pain  or 
cerebral  irritation  suggest  the  possibility  of  perforation, 
an  external  operation  becomes  necessary. 

As  a  substitute  for  an  external  opening  Schaeffer  and 
others  have  penetrated  into  the  frontal  sinus  from  the  nose 
by  boring  upward  with  a  scoop,  either  between  the  middle 
turbinal  and  roof  of  the  nose,  or  along  the  natural  chan- 
nel from  the  sinus  to  the  infundibulum.  These  attempts 
have  been  justly  abandoned  by  most  surgeons,  as  they 
involve  the  risk  of  penetrating  into  the  cranial  cavity. 

59.  Of  all  external  surgical  procedures,  Kuhnt's  opera- 
tion has  received  the  most  extensive  trial  and  has  given 
satisfactory  results.  An  incision  is  made  down  to  the 
bone  in  the  hairy  part  of  the  brow,  through  two-thirds 
of  its  length,  beginning  at  the  nasal  end.  The  brow 
hides  the  resulting  scar,  and  as  the  hairs  can  be  satis- 
factorily sterilized,  it  is  best  not  to  shave  them  off.  A 
vertical  incision  about  3  cm.  long  is  then  extended 
upward  in  the  crease  made  by  the  corrugator  muscle. 
The  periosteum  is  detached  from  the  bone,  which  some- 
times is  difficult  to  do,  and  a  triangular  flap  is  lifted 
upward  and  outward.  The  front  wall  of  the  sinus  is 
entered  either  by  a  trephine  run  by  a  motor  or  by  means 
of  a  chisel,  and  if  the  sinus  is  found  filled  with  granula- 
tions, the  entire  anterior  wall  is  resected.  The  entire 
mucous  membrane  is  removed  by  curetting,  with  pains 
to  enter  every  recess,    including  the  sinus  end   of  the 


INFLAMMATION    OF    THE    FRONTAL   SINUS.  I43 

frontal  duct.  The  duct  is  thoroughly  cleared  or  enlarged 
down  to  the  nose,  and  the  wound  is  thereupon  sutured, 
leaving  only  a  small  gap  for  a  gauze  drain  at  the  median 
end.  The  posterior  wall  is  closely  inspected  and  probed 
if  there  is  any  suspicion  of  extension  to  the  cranial  cavity. 
In  case  a  cerebral  abscess  is  suspected,  it  can  be  sought 
and  opened  after  cautious  resection  of  the  posterior  sinus 
wall.  Under  daily  irrigations  through  the  wound  a  cure 
is  usually  attained  inside  of  six  weeks.  The  sinus 
becomes  obliterated,  and  the  skin-flap  sinks  in,  but  the 
resulting  disfigurement  is  not  very  conspicuous.  The 
only  objection  against  the  operation  is  that  in  case  of 
multiple  disease  of  the  frontal  sinus  and  the  ethmoid 
cells  the  latter  cannot  be  easily  reached  through  the 
wound. 

It  is  needless  to  specify  all  the  various  modifications  of 
this  operation  which  have  been  devised,  but  not  exten- 
sively tried.  Jansen  resects  the  inferior  (orbital)  wall  of  the 
sinus  and  thereby  gains  easier  access  to  the  ethmoid  .cells 
if  required.  His  results  are  good,  but  are  attended  with 
considerable  disfigurement.  An  osteoplastic  operation 
with  the  immediate  replacement  of  the  bony  flap  has 
been  practised  by  Czerny,  Killian,  and  others.  Goluvin 
has  performed  the  same  operation  with  a  device  to  pre- 
vent disfigurement.  His  incision  is  like  that  of  Kuhnt. 
Upon  raising  the  skin-flap,  without  periosteum,  he 
chisels  a  flap  through  bone  and  periosteum,  with  con- 
vexity upward,  and  hinges  it  forward  by  breaking  it  at 
its  inferior  base.  The  sinus  is  then  curetted,  thorough 
connection  established  with  the  nose,  the  bony  flap  re- 
placed, and  the  skin  sutured  completely.  The  subse- 
quent treatment  is  entirely  carried  out  through  the  nose. 
The  same  author  has  also  reported  a  series  of  cases  in 
which  good,  quick,  and  permanent  results  were  obtained 
by  making  merely  a  small  trephine  opening  and  destroy- 
ing the  diseased  lining  of  the  sinus  by  means  of  steam. 
The  steam  is  conducted  from  a  small  boiler  through  rub- 
ber tubing  and  a  rubber  cannula  into  the  opening  made 


144  DISEASES    OF    THE    ETHMOID    CELLS. 

by  the  trephine,  and  allowed  to  act  for  from  one-quarter 
to  one-half  of  a  minute.  The  result  is  obliteration  of  the 
sinus  by  ossification.  The  wound  should  be  kept  open 
and  drained  until  dry. 

SUPPURATION  OF  THE  ETHMOID  CELLS. 

60.  The  ethmoid  cells  have  not  received  as  much  atten- 
tion at  autopsies  as  the  other  accessory  cavities,  and  hence 
we  possess  less  accurate  information  regarding  the  fre- 
quency of  their  involvement  in  disease.  Clinically,  ethmoid 
suppuration  is  nearly,  if  not  quite,  as  frequent  as  disease 
of  the  maxillary  sinus,  but  it  is  probably  not  recognized 
as  often.  It  takes  its  start  from  an  ordinary  coryza,  an 
influenza-rhinitis,  or  more  insidiously  from  some  sys- 
temic infection.  Very  little  is  known  clinically  about 
the  acute  stage  of  ethmoiditis.  It  is  ordinarily  observed 
in  its  chronic  form.  There  may  not  be  any  but  nasal 
symptoms.  A  number  of  patients,  however,  complain 
of  more  or  less  severe,  though  not  characteristic,  head- 
aches, without  definite  localization;  sometimes  of  peri- 
odic attacks  of  migrain.  There  is  sometimes  tenderness 
to  pressure  over  the  bridge  of  the  nose.  Mental  irri- 
tability, depression,  less  commonly  vertigo,  may  or  may 
not  be  present.  Long-continued  suppuration  may  itself 
be  the  starting-point  of  severe  neurasthenia.  The  inten- 
sity of  suffering  depends  somewhat  on  the  neuropathic 
disposition  of  the  patient.  Intolerance  to  alcohol  has 
been  often  observed. 

But  in  other  patients  there  may  be  none  but  nasal 
symptoms,  and  possibly  these  even  of  moderate  degree. 
Except  in  very  wide  passages  there  is  always  more  or 
less  obstruction.  This  is  partly  due  to  transient  venous 
turgescence.  In  many  instances,  however,  the  obstruc- 
tion depends  upon  the  presence  of  polypi.  Of  all  the 
various  forms  of  sinus  disease,  none  are  more  frequently 
productive  of  polypi  than  suppuration  of  the  ethmoid 
cells.  But  this  coincidence  is  not  invariable,  and,  on  the 
other  hand,  polypi  may  occur  without  ethmoid  suppura- 


SUPPURATION    OF   THE    ETHMOID    CELLS.  I45 

tion.  Yet  the  presence  of  polypi  with  purulent  discharge 
should  always  raise  a  strong  suspicion  of  ethmoid  disease. 
The  disease  is  perhaps  as  often  bilateral  as  one-sided. 

In  a  certain  number  of  instances  ethmoid  suppuration 
is  either  accompanied  by  ozena  or  produces  the  entire 
train  of  symptoms  which  we  term  ozena.  The  discharge 
may  dry  in  the  form  of  adherent  crusts  of  characteristic 
foul  odor,  with  the  appearance  of  atrophy  of  the  inferior 
turbinal.  It  is  at  present  impossible  to  state  definitely 
the  relationship  between  ozena  and  suppuration  of  the 
ethmoid  or  other  accessory  cavities.  There  is  every  reason 
to  believe  that  ozena  can  exist  as  a  diffuse  disease  of  the 
nasal  lining,  without  involvement  of  any  of  the  sinuses. 
Sinus  disease,  however,  is  at  least  a  frequent  complication 
of  ozena,  and,  on  the  other  hand,  there  are  some  instances 
in  which  the  entire  clinical  picture  of  ozena  ceases  after 
the  cure  of  a  suppurating  sinus  or  ethmoid  cell. 

61.  Apart  from  the  cases  presenting  the  appearance  of 
ozena,  the  discharge  is  a  creamy  pus  or  purulent  mucus, 
sometimes  bland,  sometimes  fetid  in  odor.  Its  apparent 
origin  varies  according  to  whether  the  anterior  or  the 
posterior  ethmoid  cells  are  diseased.  In  involvement  of 
the  anterior  ethmoid  cells  the  pus  issues  underneath  the 
middle  turbinal  near  its  front  end.  As  a  rule,  it  flows 
toward  the  anterior  nares,  but  occasionally  through  the 
middle  meatus  to  the  posterior  choanse,  thence  dropping 
into  the  throat.  Its  path  can  then  be  seen  in  the  post- 
rhinoscopic  mirror.  Suppuration  of  the  anterior  ethmoid 
cells  can  be  assumed  whenever  pus  in  any  quantity  flows 
into  the  middle  meatus,  and  disease  of  the  maxillary  and 
frontal  sinuses  can  be  excluded.  In  multiple  empyema, 
in  which  the  ethmoid  cells  participate  as  well  as  one  or 
the  other  of  the  other  accessory  cavities,  or  both,  the 
diagnosis  of  ethmoiditis  can  be  made  gradually  only 
after  emptying  the  other  sinuses,  and  still  finding  pus 
issuing  forth.  It  is  sometimes  necessary  to  tampon  the 
middle  meatus  with  bits  of  cotton  temporarily  in  order 
to  demonstrate  the  source  of  the  pus.  Probing  of  the 
10 


146  DISEASES    OF   THE    ETHMOID    CELLS. 

anterior  ethmoid  cells  is  very  uncertain  and  not  definitely 
indicative  of  their  disease.  The  probe  can  be  passed 
into  one  or  more  orifices  upward  and  slightly  outward 
underneath  the  middle  turbinal.  If  pus  can  be  removed 
by  irrigation  through  a  slender  cannula  introduced  into 
these  spaces,  the  diagnosis  is  more  definite.  These 
measures  are  all  facilitated  by  the  removal  of  the  front 
end  of  the  middle  turbinal. 

The  secretion  from  the  posterior  ethmoid  cells  issues 
through  orifices  above  the  middle  turbinal  into  the  supe- 
rior meatus  of  the  nose.  When  the  olfactory  fissure  is 
seen  filled  with  pus,  this  fluid  comes  either  from  the 
posterior  ethmoid  cells  or  from  the  sphenoid  sinus.  The 
distinction  is  neither  easy  nor  always  possible.  The 
diagnosis  is  largely  based  upon  exclusion  of  sphenoid 
disease,  according  to  the  methods  given  in  ^  66. 

The  recognition  of  disease  of  the  posterior  ethmoid 
cells  may  be  more  definite  after  space  has  been  gained  by 
removal  of  the  middle  turbinal.  This  can  usually  be 
done  only  gradually  by  snaring  off  the  front  end  and 
subsequently  the  rear  end,  and  finishing  with  cutting 
forceps.  The  pus  from  the  posterior  ethmoid  cells  is  as 
likely  to  flow  into  the  pharynx  as  into  the  anterior  nares. 
Not  rarely  it  forms  adherent  crusts  at  the  roof  of  the 
pharynx. 

Besides  empyema  of  the  ethmoid  cells  with  escape  of 
pus  into  the  nose,  we  must  recognize  a  form  of  eth- 
moiditis  with  confined  secretion  (mucocele).  The  fluid 
is  more  likely  to  be  mucous  or  mucopurulent  than  pure 
pus  in  these  cases.  Its  accumulation  causes  distention 
of  the  cell  in  which  it  is  found.  This  may  be  a  cell 
intruded  into  the  front  end  of  the  middle  turbinal,  or  it 
may  be  the  ethmoid  bulla  imderneath  the  middle  tur- 
binal, which,  when  enlarged,  appears  as  a  reduplication 
of  the  turbinated  process.  Confined  secretion  reveals 
itself  in  these  instances  by  nasal  irritation,  stuffiness,  or 
headaches.  On  inspection  a  distended,  bony  tumor  is 
seen  protruding  into  the  nose.     Confinement  of  secretion 


SUPPURATION    OF    THE    ETHMOID    CELLS.  1 47 

with  distention  may  also  occur  in  the  cells  adjoining  the 
lamina  papyracea.  In  that  case  a  bulging  appears  at  the 
inner  wall  of  the  orbit.  Perforation  may  take  place  into 
the  orbit  with  results  similar  to  those  caused  by  perfora- 
tion of  the  frontal  sinus.  Encroachment  upon  the  orbital 
space  starts  from  ethmoid  cells  oftener  than  from  the 
frontal  sinus,  and  the  site  of  the  tumefaction  is  below  the 
inferior  wall  of  the  frontal  sinus.  Pressure  upon  such 
orbital  tumefaction  gives  to  the  finger  the  same  sensation 
of  yielding  as  when  the  thin  cover  of  a  tin  can  is  pressed 
upon. 

62.  Apart  from  the  orbital  symptoms  produced  by  the 
bulging  of  the  lamina  papyracea  or  its  perforation,  eth- 
moid disease  may  lead  to  various  ocular  disturbances. 
Asthenopia  is  not  uncommon.  Recurrent  iritis  is  some- 
times observed.  The  writer  has  seen  repeatedly  a  peri- 
pheral palsy  of  ocular  muscles,  the  coincidence  of  which 
with  an  exacerbation  of  one-sided  ethmoid  disease  was  a 
strong  reason  for  suspecting  the  latter  as  the  etiologic 
starting-point.  There  are  on  record  a  moderate  number 
of  well-authenticated  instances  of  fatal  meningitis  re- 
sulting from  suppuration  of  the  ethmoid  cells.  Eth- 
moid empyema,  like  other  forms  of  nasal  suppuration, 
is  likely  to  induce  secondary  hypertrophic  changes  in  the 
nose  and  pharynx,  with  occasional  extension  into  the 
larynx  or  even  further  down. 

63.  The  lesion  in  suppuration  of  the  ethmoid  cells  is  at 
first  inflammation  of  the  mucous  membrane.  It  is  charac- 
teristic of  the  lining  of  these  spaces  that  it  swells  readily 
in  response  to  irritation.  Acute  inflammation  may  cause 
edema,  which  makes  the  mucous  membrane  protrude 
wherever  it  is  not  confined.  After  amputation  of  the 
front  end  of  the  turbinal  the  lining  membrane  underneath 
will  often  appear  swollen  and  polypoid  shortly  after 
exposure.  This  acute  condition  may  subside  completely. 
But  in  the  course  of  more  persistent  inflammation,  hyper- 
trophy of  a  permanent  character  takes  place.  Hence 
ethmoid  suppuration  is  often  accompanied  by  hypertro- 


148  DISEASES    OF   THE    ETHMOID    CELLS. 

phies  of  the  mucous  membrane  aud  true  polypi.  In  the 
course  of  time  the  thin  bony  lamellae  become  involved,  as 
the  mucous  membrane  and  periosteum  are  practically 
continuous.  The  bony  lesions  are  partly  those  of  a  rare- 
fying ostitis  with  partial  absorption,  partly  thickening  of 
the  bony  plates  secondary  to  proliferative  periostitis.  In 
rare  cases  the  disease  may  be  limited  to  but  one  or  a  few 
cells.  More  commonly  suppuration  extends  through  an 
entire  series  of  ethmoid  cells,  anterior  or  posterior,  or 
sometimes  both. 

Woakes,  who  first  drew  attention  to  the  frequency  of  ethmoid 
suppuration,  vitiated  his  clinical  observations  by  false  pathologic 
notions.  He  described,  as  the  basis  of  the  disease,  necrosis  of 
the  bone,  "  necrosing  ethmoiditis."  His  theory,  accepted  to  some 
extent  by  clinicists,  has  been  entirely  refuted  by  anatomic  re- 
search. Necrosis  and  caries  of  the  bony  walls  play  a  very  small 
role  in  ordinary  forms  of  suppuration  of  the  ethmoid  cells.  De- 
struction of  bone  may  be  a  secondary  complication  in  very  severe 
disease.  But,  on  the  whole,  it  is  not  common,  except  as  the 
result  of  syphilis,  or,  less  frequently,  tuberculosis. 

64.  The  treatment  of  ethmoid  disease  requires,  in  the 
first  place,  the  removal  of  all  polypi  and  hypertrophies  of 
the  nasal  lining.  If  these  are  difficult  of  access,  it  is  best 
to  snare  off  the  middle  turbinal  at  its  front  or  even  at  its 
rear  end.  Under  the  use  of  the  douche,  or,  still  better, 
irrigation  through  a  slender  cannula  brought  close  to  the 
ethmoid  orifices,  a  small  number  of  cases  will  heal  in  the 
course  of  weeks.  The  larger  proportion  are  only  bene- 
fited, but  not  cured,  by  this  treatment.  A  more  radical 
measure  is  the  exposure  of  the  suppurating  cells,  usually 
after  resection  of  the  middle  turbinal.  The  safest  and 
most  satisfactory  instrument  is  the  sharp  nasal  hook, 
suggested  by  Hajek  (Fig.  49).  This  is  not  likely  to  do 
accidental  damage,  which  must  be  feared  when  drills  ate 
employed.  The  hook  follows  the  path  previously  ex- 
plored by  the  probe  when  searching  for  the  origin  of  the 
pus.  The  suspected  orifices  under  the  insertion  of  the 
middle  turbinal  are  entered  and  torn  open.     As  a  rule, 


SUPPURATION    OF    THE   ETHMOID    CELLS,  I49 

the  slender  hook  suffices;  if  necessary,  the  heavier  model 
is  employed.  Each  suspected  cell  is  torn  open,  and  the 
shreds  of  the  mucous  membrane  and  bone  are  clipped  off 
with  cutting  forceps.  There  is  generally  enough  bleed- 
ing to  necessitate  the  gradual  performance  of  the  opera- 
tion at  successive  times.  In  searching  for  the  posterior 
cells,  the  hook  passes  into  the  olfactory  fissure  above  the 
middle  turbinal.  As  long  as  the  nasal  roof  is  avoided 
there  is  no  risk  in  these  manipulations.  As  soon  as  a 
suppurating  cell  is  thus  completely  exposed  and  drained, 
the  symptoms  caused  by  it,  especially  the  headache, 
cease  promptly.  As  long,  however,  as  symptoms  con- 
tinue, the  surgeon  must  try  to  follow  the  channels  of 
suppuration  by  opening  other  cells  or  breaking  down  the 


Fig.  49. — Hajek's  hooks.     They  fit  into  the  usual  nasal  handle  at  an  obtuse 

angle. 

thin  partitions  between  them  by  means  of  curets.  The 
treatment,  therefore,  is  very  apt  to  be  tedious,  but  it  is 
sure  to  give  relief.  Still  only  a  small  proportion  of 
patients  are  completely  cured.  In  the  majority  the  dis- 
tressing symptoms  are  relieved,  but  the  secretion  is  not 
entirely  stopped. 

The  treatment  is  simple  and  quite  efficacious  in  case 
of  secretion  pent  up  in  one  or  a  few  ethmoid  cells — the 
so-called  ethmoid  mucocele.  It  suffices  to  expose  these 
cells  thoroughly  by  removal  of  the  bony  wall.  Accord- 
ing to  the  location  and  prominence  of  the  distended  cell, 
this  can  be  done  either  with  a  snare  or  the  hook,  or  a 
hand-drill,  and  finished  with  a  curet  or  cutting  forceps. 

In   exceptional  cases  of  alarming  severity,  and  espe- 


150  DISEASES    OF    THE   SPHENOID   SINUS. 

cially  in  instances  of  multiple  empyema,  it  may  prove 
necessary  to  perform  an  operation  from  the  outside,  with 
complete  exposure  of  all  the  ethmoid  cells.  This  opera- 
tion will  be  referred  to  under  the  head  of  Multiple 
Empyema. 

INFLAMMATION  OF  THE  SPHENOID  SINUS. 

65,  The  sphenoid  cavity  is  frequently  found  diseased 
in  autopsies.  But  clinically  affections  of  this  space  are 
not  observed  so  commonly,  probably  because  they  are 
often  overlooked.  The  symptoms  are  not  definite.  We 
do  not  know  how  many  cases  run  a  latent  course,  the 
disease  causing  merely  nasal  suppuration  and  obstruction. 
The  pus  is  observed  in  the  olfactory  fissure,  between 
middle  turbinal  and  septum,  more  often  one-sided  than 
bilateral.  It  is  as  likely  to  flow  through  the  posterior 
choanse  as  into  the  anterior  nares.  In  some  instances 
sphenoid  suppuration  produces  the  symptoms  of  ozena — 
viz.,  fetid,  adherent  crusts,  with  tendency  to  atrophy  of 
the  inferior  turbinal.  Probably,  many  of  the  instances  of 
crust  formation  at  the  roof  of  the  pharynx  are  due  really 
to  sphenoid  suppuration.  The  nasal  obstruction  which 
may  result  from  sphenoid  affections  is  due  mainly  to 
turgescence  of  the  rear  ends  of  the  turbinal.  In  fact, 
every  periodic  engorgement  of  the  cavernous  tissue  at  the 
level  of  the  posterior  choanse  should  direct  suspicion 
toward  the  sphenoid  sinus. 

When  headache  is  present,  it  is  generally  of  a  severe 
type  and  not  definitely  localized.  It  seems  to  be  a  fairly 
frequent  symptom.  The  disease  starts  sometimes  in  an 
acute  manner — for  instance,  after  influenza.  In  other 
cases  its  origin  cannot  be.  traced.  Eye  symptoms  in  the 
form  of  asthenopia  are  not  uncommon.  Extension  of 
the  disease  through  the  upper  wall  has  in  some  instances 
caused  optic  neuritis,  in  others  atrophy  of  the  optic 
nerves.  Caries  of  the  sphenoid  walls,  though  probably  not 
common,  has  been  observed.  It  has  caused  fatal  hemor- 
rhage by  erosion  of  the  carotid  artery.     Thrombosis  of 


INFLAMMATION    OF   THE    SPHENOID    SINUS.  151 

the  cavernous  sinus  is  likewise  a  possible  consequence,  as 
well  as  fatal  meningitis. 

66.  The  diagnosis  depends  upon  exploration  of  the 
sphenoid  sinus  through  its  orifice.  If  the  probe  slants 
sufficiently  backward  and  upward,  it  is  bound  to  touch 
the  anterior  surface  of  the  sphenoid  body.  By  holding  it 
nearly  vertical  and  probing  too  near  the  front  end  of  the 
middle  turbinal  its  tip  reaches  the  dangerous  nasal  roof 
But  by  crossing  the  middle  turbinal  behind  its  center  this 
danger  is  avoided.  The  sphenoid  orifice  is  situated  close 
to  the  roof  of  the  nose  and  nearer  to  the  lateral  wall  than 
to  the  septum.  By  bending  the  tip  of  the  probe  a  trifle 
upward,  it  is  quite  often  possible  to  enter  the  sphenoid 
orifice.  The  distance  from  the  inferior  rim  of  the  pyriform 
aperture  to  the  sphenoid  opening  varies  from  6  to  8  cm. 
in  the  adult.  After  entering  the  orifice  the  probe  can  then 
slip  into  the  sinus  to  the  extent  of  i  to  2|  cm.  When 
pus  issues  next  to  the  probe  or  adheres  to  the  probe,  the 
diagnosis  is  established.  If  this  test  fails,  a  slender 
cannula  can  be  substituted  for  the  probe,  and  an  attempt 
made  to  dislodge  the  sphenoid  secretion  by  warm  salt 
solution.  It  is  often  difliicult,  sometimes  impossible,  to 
distinguish  between  suppuration  of  the  posterior  ethmoid 
cells  and  of  the  sphenoid  sinus  until  the  middle  turbinal 
has  been  nearly  entirely  removed. 

67.  Treatment. — When  the  inflammatory  process  in  the 
sphenoid  is  of  a  superficial  character,  a  few  irrigations 
through  the  natural  orifice  will  sometimes  terminate  the 
disease.  In  instances  attended  with  suffering,  the  first 
successful  irrigation  gives  relief  If  irrigation  through  the 
natural  opening  proves  impossible  or  insufficient,  the  ante- 
rior wall  of  the  sinus  can  be  opened  in  the  safest  manner 
by  means  of  Hajek's  hook.  Traction  with  a  hook  does  not 
involve  the  risk  of  slipping  that  attends  the  use  of  a  drill 
or  a  perforating  curet.  The  opening  of  the  sinus  suffices 
for  a  gradual  cure,  except  when  its  interior  lining  is  per- 
manently hypertrophied.  In  such  instances  the  mucous 
membrane  has  been  successfully  removed  by  means  of 


152    MULTIPLE    EMPYEMA    OF   SEVERAL   ACCESSORY    CAVITIES. 

the  curet  or  the  introduction  of  a  pledget  of  cotton  on  a 
probe  moistened  with  chlorid  of  zinc  solution.  This 
should  be  introduced  through  a  tube  in  order  to  protect 
the  nasal  lining.  On  account  of  the  possible  thinness  of 
the  upper  wall  of  the  sinus,  Hajek  advises  as  the  safer 
method  the  evulsion  of  the  thickened  mucous  membrane 
with  forceps  rather  than  with  a  curet  working  in  the  con- 
fined space.  The  use  of  the  curet  on  the  inferior  wall 
involves  no  risk.  In  the  majority  of  instances,  suppura- 
tion of  the  sphenoid  sinus  can  be  controlled  by  treatment 
with  more  certainty  than  extensive  disease  of  the  ethmoid 
cells. 

MULTIPLE    EMPYEMA    OF    SEVERAL    ACCESSORY    CAVI= 

TIES. 

68.  Although  sinuitis  is  mostly  limited  to  one  cavity, 
multiple  disease  of  several  spaces  is  not  uncommon.  Such 
instances  may  be  one-sided  or  bilateral,  in  the  latter  cases 
perhaps  most  frequently  with  symmetric  involvement 
on  both  sides.  In  the  case  of  the  frontal  sinus  bilateral 
disease  is  sometimes  due  to  a  defect  or  morbid  perforation 
of  the  median  partition  wall.  The  spaces  which  partici- 
pate the  oftenest  in  multiple  empyema  are  the  ethmoid 
cells,  the  anterior  in  connection  with  maxillary  or  frontal 
sinus  disease,  the  posterior  with  sphenoid  suppuration. 
Occasionally  all  cavities  are  found  diseased  on  one  or 
even  both  sides. 

As  in  the  case  of  disease  of  a  single  sinus,  the  symp- 
toms may  vary  greatly.  On  the  one  hand,  a  few 
patients  complain  of  nothing  but  a  ver>'  profuse  discharge. 
It  is  remarkable  how  little  disturbance  of  health  there 
may  be  in  such  exceptional  cases.  On  the  other  hand, 
there  may  be,  besides  the  local  discomfort  and  the  nasal 
secondary  disturbances,  headaches  of  great  severity, 
general  malnutrition,  and  neurasthenia,  until  the  patient 
becomes  a  physical  wreck. 

The  diagnosis  can  be  made  only  gradually,  as  the  in- 
volvement of  one  cavity  after  another  is  being  recognized. 


TREATMENT.  153 

Efforts  must  be  made  to  trace  the  origin  of  the  pus  ac- 
cording to  the  indications  discussed  previously. 

69.  In  instances  in  which  no  severe  or  dangerous 
symptoms  are  present,  the  attempt  may  be  made  to  expose 
the  suppurating  spaces  by  the  same  intranasal  operations 
which  apply  in  disease  of  each  individual  sinus.  But 
whenever  urgency  is  called  for,  a  more  radical  method  is 
the  free  opening  of  the  accessory  spaces  from  the  outside. 
A  number  of  different  modifications  of  osteoplastic  opera- 
tions have  been  devised  by  Gussenbauer,  Winkler,  and 
Killian.  All  of  them  give  fairly  satisfactory  results; 
none  of  them  have  received  extensive  trial.  The  prin- 
ciple of  such  an  operation  for  one  side  at  a  time  is  the 
following: 

General  narcosis,  tamponing  of  the  nasopharynx,  in- 
cision down  to  the  bone  in  the  median  line  from  the 
upper  level  of  the  frontal  sinus  along  the  bridge  of  the 
nose  down  to  beyond  the  lower  border  of  the  nasal  bone, 
pushing  back  the  periosteum  sufficiently  for  separation 
of  the  nasal  bones  at  the  nasofrontal  suture.  Sub- 
periosteal resection  at  the  same  level  through  frontal 
process  of  superior  maxilla  with  a  fine  saw  or  chisel, 
opening  the  bony  frame  of  the  external  nose  through  the 
suture  between  the  two  nasal  bones,  and  pushing  outward 
the  external  wall  of  the  nose  (nasal  bone  and  frontal 
process  of  submaxilla),  if  necessary  after  grooving  along 
its  nasal  surface  in  case  it  offers  too  much  resistance. 
The  ethmoid  cells  can  now  be  entered  from  the  front, 
and  by  breaking  down  all  cross  partitions  and  septa  with 
forceps,  they  can  be  changed  into  a  single  continuous 
space  from  lamina  papyracea  to  middle  turbinal,  opening 
freely  into  the  nose.  The  operation  can  be  extended  to 
the  anterior  sphenoid  wall,  and  the  sphenoid  sinus  ex- 
posed. In  case  of  frontal  empyema  a  horizontal  incision 
is  extended  through  the  brow,  a  portion  of  the  anterior 
wall  of  the  sinus  is  resected,  the  duct  identified  by  a 
probe  introduced  into  it,  and  the  floor  of  the  sinus  chiseled 
away  as  far  as  it  is  accessible  from  the  nose.     Gauze  tam- 


154    MULTIPLE   EMPYEMA    OF   SEVERAL   ACCESSORY    CAVITIES. 

pons  leading  into  the  nose,  replacing  of  bone  flaps, 
primary  or  early  secondary  suture.  After-treatment 
through  the  nose. 

In  Gussenbauer's  operation  for  bilateral  disease  the  cu- 
taneous incision  begins  near  the  middle  of  each  eyebrow, 
runs  down  vertically  (about  5  mm.  beyond  the  internal 
canthus)  along  the  sides  of  the  nose,  and  connects  across 
the  nose  at  the  lower  border  of  the  nasal  bones.  A  single 
bony  flap  is  made  of  all  the  nasal  walls  circumscribed  by 
the  incision,  including  the  lachrymal  bone  and  a  slice  of 
the  lamina  papyracea,  as  well  as  the  perpendicular  plate 
of  the  ethmoid.  After  sawing  and  chiseling  through  all 
connections,  the  flap  is  reflected  upward  and  access  ob- 
tained to  the  upper  part  of  the  interior  of  the  nose  and 
the  entire  ethmoid  labyrinth  on  both  sides.  After  the 
complete  exenteration  of  all  diseased  spaces  the  flap  is 
replaced. 


CHAPTER   IX. 

OZENA    (FETID  ATROPHIC   RHINITIS) — SIMPLE 
ATROPHIC    RHINITIS. 

70.  Symptoms  and  Course. — Atrophic  rhinitis  is  char- 
acterized by  a  purulent  secretion,  drying  in  the  form  of 
adherent  crusts,  and  accompanied  by  progressive  atrophy 
of  the  nasal  mucous  lining  and  of  the  turbinated  bones. 
In  the  "simple"  form  the  crusts  are  nearly  odorless;  in 
the  fetid  form — the  more  common  variety — the  crusts 
have  a  very  strong  offensive  and  characteristic  smell. 
As  the  fetid  form  can  be  changed  by  treatment  into  the 
odorless  simple  form,  the  two  varieties  of  the  disease — 
similar   in  course — may  be  considered  under  one  head. 

The  beginning  of  the  disease  has  been  but  little  de- 
scribed and  is  probably  not  seen  often.  In  some  personal 
observations  it  began  as  a  minimal  localized  focus  of 
characteristic  suppuration  on  the  middle  turbinal,  with 
crust-formation  gradually  extending  in  area.  The  sub- 
jective annoyance  is  but  moderate.  There  is  some 
transient  obstruction  when  large  scabs  form,  which 
diminishes,  however,  as  the  atrophy  proceeds.  The 
crusts  cause  the  patient  to  blow  forcibly  in  order  to  expel 
them,  as  there  is  but  little  fluid  discharge.  In  neurotic 
subjects  severe  headaches,  both  more  or  less  irregularly 
continuous  pain,  as  well  as  periodic  attacks  of  migrain, 
are  not  uncommon.  The  patients  have  occasional  fresh 
"colds,"  with  increased  discharge,  but  these  attacks  are 
both  less  severe  and  less  common  in  atrophic  rhinitis  than 
in  other  chronic  forms  of  nasal  disease.  They  cease 
almost  entirely  when  the  atrophy  has  advanced  far.  The 
most  distressing  symptom,  present  only  in  the  fetid  form, 
is  the  foul  odor  noticeable  sometimes  across  the  room, 
but  not  perceptible  to  the  patient.     The  patient's  sense 

155 


156  OZENA.— SIMPLE    ATROPHIC    RHINITIS. 

of  smell  is  often  reduced,  especially  when  there  is  abun- 
dant scab-formation. 

The  discharge  is  viscid  greenish-yellow,  and  so  tena- 
cious that  it  does  not  flow  along  the  mucous  surface,  but 
adheres  and  dries  superficially,  forming  scabs  with  some 
thick  fluid  underneath.  It  is  formed  mainly  around  and 
opposite  the  middle  turbinal,  but  is,  of  course,  gradually 
pushed  down  by  further  flow  from  above.  A  large  part 
of  the  nasal  walls  may  thus  be  lined  with  crusts.  The 
amount  of  crust-formation  varies.  In  many  cases  casts 
are  found  at  the  roof  of  the  pharynx.  Occasionally  the 
disease  seems  to  be  limited  to  this  locality  alone.  When 
the  disease  improves  under  treatment,  the  pus  becomes 
more  fluid,  less  greenish,  and  changes  finally  into  a 
slightly  purulent  mucus.  The  odor  in  the  fetid  variety 
is  so  characteristic  that  an  experienced  diagnostician  can 
distinguish  it  at  once  from  the  smell  of  either  syphilitic 
necrosis  or  of  suppurative  sinuitis  with  retention.  But 
the  odor  is  not  inherent  in  the  fresh  discharge:  it  is  the 
result  of  secondary  changes.  When  the  crusts  have  been 
thoroughly  removed  and  are  not  allowed  to  form  again  by 
proper  tamponage  of  the  nose,  the  pus  upon  the  tampon 
has  merely  d  slightly  mawkish  odor,  as  in  the  simple, 
non-fetid  variety.  The  fetid  form  can  thus  be  transformed 
into  the  non-fetid  variety,  but  usually  changes  back  in 
the  course  of  weeks  when  the  treatment  ceases.  Whether 
the  non-fetid  form  occurring  spontaneously  acquires  the 
odor  in  the  course  of  time  is  not  known.  But  while  the 
odor  is  thus  a  secondary  feature,  it  is  one  of  great  impor- 
tance, for  not  only  is  it  the  main  annoyance  to  the  patient, 
but  the  changes  which  cause  the  odor  are,  by  themselves, 
a  significant  factor  in  the  course  of  the  disease.  The  sim- 
ple non-fetid  atrophic  rhinitis — much  less  common  than 
the  typical  form  of  ozena — shows  neither  as  much  dis- 
charge nor  as  much  atrophy  as  is  usually  found  in  ad- 
vanced cases  of  fetid  ozena. 

71.  The  atrophy  of  this  disease  is  a  gradually  increasing 
process.     Scarcely  recognizable  at  first,  it  continues  until 


PATHOLOGY.  1 57 

the  passages  have  become  abnormally  wide  and  the 
complex  architecture  of  the  turbinals  is  reduced  to  rudi- 
mentary ledges.  When  ozena  occurs  in  a  nose  with 
strongly  deflected  septum,  the  atrophic  process  is  always 
much  less  pronounced  on  the  side  narrowed  by  the  con- 
vexity of  the  septum.  In  extreme  cases  of  this  kind  the 
disease  seems  to  be  almost  wholly  one-sided,  while  ordi- 
narily it  is  symmetric.  The  atrophy  involves  the  entire 
mucous  membrane.  The  venous  plexus  shrinks  likewise, 
and  turgescence  becomes  finally  impossible.  Even  in 
the  living  it  is  evident  that  the  atrophy  involves  also 
the  bony  structure  of  the  turbinals  and  leads  to  their 
reduction  in  size  and  partial  absorption.  Ulceration  and 
caries  of  bone  are,  however,  never  found  in  ozena.  Oc- 
casionally a  circumscribed  hypertrophy  of  the  mucous 
membrane  over  a  part  of  a  turbinal — probably  antedating 
the  ozena — persists  for  a  while.  Hypertrophy  of  the 
pharyngeal  tonsil  is  conspicuously  absent.  Moderate 
enlargement  of  the  faucial  tonsil  is  sometimes  met  with. 

Ozena  begins  mostly  in  childhood  after  about  the 
sixth  to  the  eighth  year,  less  commonly  in  adolescence. 
The  fetid  variety  is  much  more  common  than  the  disease 
without  odor.  The  female  sex  preponderates  markedly. 
The  disease  continues  an  indefinite  period,  but  probably 
ceases  in  some  instances  spontaneously  in  middle  or  ad- 
vanced life.     The  atrophy,  however,  remains. 

Ozena  does  not  often  lead  to  complications.  Ulcerative 
blepharitis  of  a  severe  type,  purulent  dacryocystitis,  less 
frequently  persistent  secretory  catarrh  of  the  middle  ear, 
are  its  possible  consequences. 

72.  Pathology. — Atrophic  rhinitis  is  an  inflammatory 
disease.  As  long  as  the  atrophy  is  not  complete,  the 
mucous  membrane  is  found  infiltrated  with  round  cells, 
both  in  a  continual  subepithelial  layer,  as  well  as  around 
arterioles  and  glands.  The  cylindric  ciliated  epithelium 
is  changed  into  non-ciliated  cuboid  pavement  cells.  The 
surface  epithelium,  as  well  as  the  gland-cells,  shows  fatty 
infiltration.      From  the  start  the  atrophic  changes  are 


158  OZENA.— SIMPLE    ATROPHIC    RHINITIS. 

unmistakable.  The  mucous  membrane  becomes  grad- 
ually thinner,  the  glands  shrink  and  finally  disappear 
largely,  while  arteries,  and  still  more  the  venous  plexus, 
atrophy  proportionately.  The  bony  skeleton  of  the  tur- 
binals  shrinks  in  all  directions  and  becomes  fragile,  show- 
ing a  histologic  picture  of  bone  absorption  (osteoclasts). 
The  atrophic  process  is  a  diffuse  one,  although  not  always 
uniformly  extensive. 

It  has  been  shown  clinically  by  Griinwald,  and  con- 
firmed by  Hajek  and  others,  that  ozena  is  often  associated 
with  suppurative  hiflammation  of  one  or  more  accessory 
cavities^  especially  the  sphenoid  sinus.  The  extreme 
view,  however,  which  considers  ozena  simply  and  in- 
variably a  manifestation  of  sinus  disease,  is  not  tenable. 
A  number  of  autopsies  have  shown  that  ozena  can  exist 
without  involvement  of  any  sinus.  Clinically,  too,  cases 
are  occasionally  observed  in  which  the  curative  influence 
of  douches  and  tampons  permits  us  to  exclude  sinus  dis- 
ease, which  would  not  yield  to  these  measures  alone.  On 
the  other  hand,  the  majority  of  unquestionable  instances 
of  suppuration  of  the  various  sinuses  do  not  present  the 
characteristic  clinical  picture  of  ozena — viz. ,  the  typical 
greenish  adherent  crusts  and  the  progressive  atrophy. 
The  odor  of  foul  pus  from  a  sinus  is  also  not  identical 
with  that  of  ozena — at  least,  as  a  rule. 

There  can  be  no  doubt,  however,  that  suppuration  of 
one  or  more  sinuses  is  an  important  and  frequent,  though 
probably  a  secondary,  lesion  in  ozena,  and  that  this  associa- 
tion explains  in  many  instances  the  inefficiency  of  treat- 
ment. It  may  even  be  stated  that  there  are  occasional 
instances  of  apparently  typical  ozena,  usually  not  far 
advanced,  in  which  the  cure  of  suppuration  from  the 
sphenoid  sinus  or  the  ethmoid  cells  puts  an  end  to  all 
manifestations  of  ozena.  The  atrophy,  however,  remains, 
but  this  has  generally  not  advanced  far  in  cases  of  this 
description. 

73.  As  the  cause  of  atrophic  rhinitis,  a  microbe  has 
been  described  by  Lowenberg  in  the  shape  of  a  coccus. 


CAUSE.  159 

But  the  same  germ  was  subsequently  identified  by  Abel 
(Paulsen  and  others)  as  a  short  bacillus — the  bacillus  mu- 
cosus  capsulatus. '  It  has  been  invariably  found,  although 
in  scant  number,  in  the  fresh  discharge  in  this  disease, 
whether  odor  was  present  or  not.  This  microbe  does  not 
give  rise  to  the  characteristic  odor  in  cultures.  It  has 
been  seen  occasionally  in  the  discharge  in  other  nasal 
diseases.  This  latter  fact  would  not  overthrow  its  etio- 
logic  significance,  as  it  is  well  known  that  different 
imquestionably  virulent  microbes  (diphtheria,  cholera, 
and  tubercle  bacilli)  can  occur  at  times  on  mucous 
surfaces  without  leading  to  infection.  But  since  this 
bacillus  is  not  found  in  the  interior  of  the  tissues,  and 
since  no  conclusive  inoculations  have  been  reported,  its 
importance  cannot  be  said  to  have  been  fully  established. 
Still,  infection  by  some  specific  form  of  microbe  is  the 
most  plausible  explanation  of  the  peculiarities  of  this 
disease.  Coexisting  inflammation  of  different  sinuses 
may,  however,  be  a  secondary  or  mixed  infection  with 
other  pyogenic  micro-organisms.  The  secretion  started 
by  this  specific  infection  differs,  at  least  quantitatively, 
in  its  composition  from  the  pus  of  other  diseases,  for  in 
other  nasal  affections  we  do  not  find  such  crusts  unless 
there  is  ulceration  present,  as  in  syphilis  and  infected 
wounds,  and  in  these  cases  the  crusts  have  not  the  charac- 
teristic odor.  Yet  the  odor  is  not  directly  due  to  the 
presumable  parasite  of  ozena,  since,  as  stated  before,  the 
smell  can  be  abolished  by  preventing  retention  and  dry- 
ing of  the  discharge,  while  in  the  simple  form  of  atrophic 
rhinitis  there  is  no  odor  at  all.     Hence  it  is  probable  that 

*  A  bacillus  about  1.25  //  thick,  of  variable  length — sometimes  so  short  as 
to  look  like  a  coccus.  Often  in  chains.  Surrounded  by  a  distinct  capsule.  The 
bacillus  is  easily  stained,  but  loses  its  color  by  the  Gram  method.  Aerobic. 
Grows  on  gelatin,  forming  thick  white  colonies  of  fluid  but  viscid  consistency, 
without  diffuse  liquefaction  of  soil.  On  potato  a  creamy  rich  growth  of  color  of 
soil.  Retains  its  life  in  culture  indefinitely.  Pathogenic  to  white  mice,  pro- 
ducing a  local  exudate  and  septicemia.  Much  less  virulent  to  other  animals. 
While  this  bacillus  belongs  to  the  same  group  as  the  pneumobacillus  of  Fried- 
Jander,  it  is  distinguishable  from  it  by  its  cultural  peculiarities. 


l6o  OZENA. —SIMPLE   ATROPHIC    RHINITIS. 

the  characteristic  smell  is  produced  by  secondary  decom- 
position of  the  pus  by  other  bacteria,  which  find  a  favor- 
able soil  in  the  pus  peculiar  to  the  "  fetid  "  form  of  this 
disease,  but  which  in  certain  other  cases — the  simple 
form — are  resisted  by  (unknown)  influences  unfavorable 
to  them.  These  secondary  decompositions  undoubtedly 
are  an  additional  pathogenic  factor  in  the  disease,  since 
any  tendency  toward  improvement  is  observed  only  when 
the  retention  and  decomposition  of  the  discharge  are  pre- 
vented artificially.  Besides  the  bacillus  mucosus  cap- 
sulatus,  other  bacteria  are  always  in  abundance  in  the 
crusts.  There  is  no  clinical  evidence  that  ozena  is  con- 
tagious. Its  rare  occurrence  in  several  members  of  one 
family  is  more  likely  due  to  congenital  anatomic  predis- 
position. 

It  is  noticeable  that  atrophic  rhinitis  occurs  usually  in 
relatively  spacious  nasal  passages.  Measurements  by 
Hopman  have  shown  that  there  is  usually  a  relative 
shortness  of  the  nasal  septum  as  compared  with  the 
depth  of  the  postnasal  space.  Atrophic  rhinitis  is  a 
purely  local  disease,  not  related  to  other  disturbances  of 
health. 

Of  the  numerous  speculative  views  regarding  the  etiology  of 
ozena,  only  two  need  to  be  mentioned — and  to  be  refuted.  Frankel 
claimed  that  ozena  is  the  terminal  stage  of  hypertrophic  rhi- 
nitis. No  one  has  ever  seen  this  transition  conclusively,  and 
the  mere  presence  of  a  h3'pertrophic  spot  in  ozena  is  insufficient 
evidence.  Moreover,  ozena  begins  usually  in  childhood,  before 
hypertrophic  rhinitis  is  at  all  common.  Bosworth  has  suggested 
that  his  "  purulent  rhinitis  of  children  "  might  be  the  beginning 
of  atrophic  disease,  but  has  also  failed  to  furnish  positive  proofs. 
According  to  personal  experience,  the  peculiarities  of  the  purulent 
rhinitis  of  children  persist  so  long  as  the  disease  lasts  and  do  not 
change  into  those  of  ozena,  while  it  is  generally  recognized  that 
the  characteristics  of  ozena  are  present  from  the  start. 

74.  The  treatment  demands  the  removal  of  the  tena- 
cious pus  and  the  prevention  of  its  desiccation.  If  the 
douche  used  with  considerable  force  does  not  detach  the 
crusts,  they  must  be  picked  off  with  forceps  and  probe. 


» 


TREATMENT.  l6l 

The  douche  should  be  continued  until  the  water  comes 
out  clear.  In  a  few  hours  the  crusts  form  again.  But 
on  irrigating  twice  a  day  properly,  the  secretion  soon 
diminishes,  becomes  clearer  and  less  tenacious,  and  crusts 
can  be  prevented.  An  important  addition,  and  to  some 
extent  a  substitute  for  the  douche,  is  the  tampon  intro- 
duced by  Gottstein.  A  pledget  of  cotton  of  the  size  of  a 
little  finger  is  pushed  up  into  the  nose  and  replaced  in 
the  course  of  hours  as  soon  as  it  feels  wet.  It  may  be 
wound  on  a  probe  with  a  screw-thread,  which  is  then 
withdrawn  by  rotation,  or  it  may  be  rolled  permanently 
on  a  wooden  tooth-pick.  Its  application  must  be  learned 
by  the  patient.  As  long  as  the  surgeon  applies  the  tam- 
pon himself,  packing  with  gauze  is,  if  anything,  more 
agreeable  to  the  patient  than  cotton.  If  possible  without 
interference  with  nasal  breathing,  the  tampon  may  be 
worn  on  both  sides  continuously,  otherwise  alternately. 
Its  use  during  the  night  depends  on  the  patient's  toler- 
ance. The  tampon  starts  a  more  abundant  but  thinner 
flow  of  mucus,  which  diminishes  in  the  course  of  some 
days.  The  tenacious  pus  is  thus  removed  more  com- 
pletely by  absorption  by  the  cotton  plug,  while  desic- 
cation becomes  impossible.  If  properly  applied  after  a 
thorough  cleansing,  the  tampon  removes  all  odor  within 
a  few  days.  On  stopping  the  treatment,  the  odor  returns 
after  a  time,  varying  in  duration  according  to  the  pre- 
vious improvement.  By  the  use  of  the  douche  and  the 
tampon,  every  case  of  ozena  can  be  made  comfortable 
and  improved  up  to  a  variable  limit.  A  small  number, 
perhaps  lo  per  cent.,  are  completely  cured  in  the  course 
of  many  weeks.  The  possibility  of  cure  depends  less  on 
the  degree  of  atrophy  than  the  absence  of  suppuration  of 
accessory  cavities. 

Griinwald  has  shown  that  ozena  rebellious  to  all  other 
treatment  can  be  cured  by  opening  up  all  foci  of  sup- 
puration in  the  different  sinuses  which  may  be  involved. 
Quite  often  the  sinuitis  is  multiple,  and  may  hence 
require  multiple  operations.  The  difficulties  of  recog- 
11 


l62  OZENA. SIMPLE   ATROPHIC    RHINITIS. 

uizing  and  curing  affections  of  the  accessory  cavities 
(compare  Chapters  VI.  to  VIII.)  are  at  present  so  great 
that  but  few  reports  have  appeared  confirming  or  limiting 
Griinwald's  claims.  The  writer's  personal  observations 
are  favorable  to  them,  but  he  can  neither  share  his  radi- 
cal views  concerning  the  all-importance  of  sinuitis,  nor 
his  sanguine  statements  regarding  their  speedy  surgical 
cure. 

Many  other  methods  of  treatment  have  been  recommended, 
but  none  have  obtained  general  indorsement.  Medicinal  applica- 
tions of  methyl-blue,  ichthyol,  oil  sprays,  mild  caustics,  and  a 
host  of  other  measures  have  found  but  little  favor  on  tests  made 
by  others  than  their  first  originators.  Electrolysis  carried  out  by 
means  of  a  copper  probe  used  as  negative  electrode  vi^ith  a  current 
of  from  15  to  25  milliamp^res  for  a  few  minutes  has  also  been 
found  uncertain,  although  at  first  highly  praised.  Massage  by 
means  of  vibratory  movements  with  a  cotton-wound  probe,  or 
with  an  electromagnetic  vibrator,  seems  to  have  given  satisfaction, 
but  definite  reports  regarding  permanent  cures  are  still  to  appear. 
Injection  of  diphtheria  antitoxin,  a  procedure  without  any  theo- 
retic foundation,  has  been  reported  curative,  but  the  unfounded 
and  arbitrary  reason  for  this  procedure  has  not  attracted  much 
confirmation. 


CHAPTER  X. 

ANTERIOR     DRY    RHINITIS.— PERFORATING     ULCER 

OF    THE   SEPTUM HEMATOMA    AND   ABSCESS 

OF    THE    SEPTUM.— MEMBRANOUS    AND    DIPH- 
THERITIC  RHINITIS. 

ANTERIOR  DRY   RHINITIS   (RHINITIS    ANTERIOR  SICCA).— 
PERFORATING   ULCER  OF  THE  SEPTUM. 

75.  Anterior  dry  rhinitis  is  the  term  applied  recently 
by  Siebenman  to  a  frequent  nasal  affection  which  had 
previously  been  ignored,  perhaps  by  reason  of  its  seeming 
innocuousness.  It  is  an  inflammation  of  the  lower  part  of 
the  cartilaginous  septum,  with  formation  of  adherent 
crusts  and  tendency  to  ulceration.  On  the  surface  of  the 
cartilaginous  septum,  barely  behind  the  vestibule  and 
just  above  the  floor  of  the  nose,  adherent  thin  scabs  are 
found — on  one  side,  as  a  rule.  They  are  not  purulent, 
and  look  like  dry  scales  of  varnish.  When  detached 
(with  difficulty),  the  surface  underneath  is  found  exco- 
riated and  liable  to  bleed.  Later  on  deeper  ulceration  may 
be  seen.  The  disease  remains  limited  to  a  small  area. 
It  has  little  tendency  to  heal  spontaneously,  and  may  last 
long  periods  of  time,  leading  in  many  instances  finally  to 
a  perforating  ulcer  of  the  septum.  As  the  disease  ad- 
vances the  mucous  membrane  is  destroyed,  and  the  cartil- 
age is  seen  exposed.  The  ulceration  extends  through  the 
center  of  this  denuded  area,  and  then  spreads  centri- 
fugally  until  a  perforation  approximately  circular  and 
rarely  over  2  cm.  in  diameter  results.  The  disease  never 
extends  beyond  this  stage,  but  the  edge  of  the  perforation 
may  remain  excoriated  for  a  long  time.  Finally  tliis  heals 
too,  and  nothing  but  a  hole  with  smooth  undeformed  edge 
remains. 

During  its  entire  course  the  disease  causes  very  little 


164  ANTERIOR    DRY    RHINITIS. 

disturbance.  The  patient  complains  of  slight  annoyance 
from  the  crusts  and  is  apt  to  pick  at  them.  Occasionally 
persistent  and  repeated  bleeding  occurs,  especially  after 
enfeebling  diseases,  like  typhoid  fever.  There  is  no 
liability  to  acute  inflammation  or  other  complications, 
but  the  disease  may  sometimes  be  associated  with  a  puru- 
lent rhinitis. 

76.  The  cause  of  dry  rhinitis  is  not  known.  ^  The  dis- 
ease is  not  ordinarily  seen  in  children.  Fragments  of 
excised  mucous  membrane  show  round-cell  infiltration, 
especially  along  the  course  of  the  blood-vessels,  some 
hyaline  degeneration  of  the  mucous  membrane,  and 
the  presence  of  plasma-cells.  Hemorrhages  occur  into 
the  tissue,  and  leave  evidence  of  their  presence  in  the 
form  of  yellowish  pigment  granules,  which  give  the 
surface  a  yellowish  appearance.  Such  discolored  areas 
have  been  described  by  Zuckerkandl  under  the  name 
xanthosis.  The  cylindric  epithelium  changes  into  flat 
cells  with  keratous  degeneration.  Later  on  the  epithelium 
is,  of  course,  lost.  The  progressiveness  is  apparently  due 
to  changes  in  the  blood-vessels.  When  it  comes  to  actual 
ulceration,  the  diseased  area  is  found  infiltrated  with 
cocci,  to  the  presence  of  which  the  destruction  must  be 
ascribed.  The  adherent  scabs  consist  of  dry  mucoserous 
secretion  with  very  few  round  cells.  Similar  adherent  and 
persisting  crusts  are  sometimes  seen  after  surgical  wounds 
in  the  cartilaginous  part  of  the  septum,  but  in  these  in- 
stances no  tendency  to  progressive  ulceration  is  observed. 

77.  The  disease  is  but  imperfectly  controlled  by  treat- 
ment, perhaps  for  the  reason  that  patients  lack  the  neces- 
sary endurance,  in  view  of  the  slight  annoyance  which  it 
causes  them.  Nitrate  of  silver  applications,  5  to  20  per 
cent,  in  strength,  exert  a  distinct,  but  not  always  per- 
manent, influence.  The  crust-formation  is  controlled 
by  cotton  tampons  as  long  as  the  patient  is  willing 
to  wear  them.     Treatment   is  likewise   inefficient   after 

^  Workmen  handling  chrome  or  arsenical  salts  or  those  manufacturing 
cements  frequently  suffer  from  ulceration  of  the  septum. 


HEMATOMA    AND    ABSCESS    OF   THE    SEPTUM.  1 65 

the  ulcer  has  perforated.  Here,  too,  nitrate  of  silver 
applied  to  the  edges  is  of  some  benefit.  Stronger  caus- 
tics or  the  galvanocaustic  burner  give  no  satisfactory 
results.  But  while  we  may  not  be  able  to  check  the 
ulceration,  we  can  be  certain  of  its  benign  and  ultimately 
limited  course. 

78.  It  is  very  important  to  distinguish  between  this 
benign  perforation  of  the  septum  and  syphilitic  ulcera- 
tion. The  former  produces  little  disturbance,  never  ex- 
tends beyond  an  area  of  about  a  five-cent  piece  in  size, 
is  approximately  round,  and  its  edges  are  not  thickened 
or  deformed  and  are  covered  only  with  thin  crusts.  It 
never  extends  beyond  the  cartilaginous  septum,  and 
when  the  edges  heal,  the  crust-formation  ceases.  Syphi- 
litic ulcers,  on  the  other  hand,  the  result  of  either  a  cir- 
cumscribed gumma  or  diffuse  gummatous  involvement  of 
the  blood-vessels,  cause  decided  disturbance,  at  first  in 
the  form  of  pain,  and  later  on  by  reason  of  the  copious 
secretion  and  the  thick  purulent  crusts.  The  edges  of 
syphilitic  ulcers  are  always  thickened,  infiltrated,  and 
more  or  less  deformed,  and  the  ulceration,  if  not  checked, 
extends  beyond  the  cartilage  into  the  bony  septum.  If 
not  controlled,  it  may  cause  extensive  loss  of  substance 
down  to  the  floor  of  the  nose  and  high  up  in  the  bony 
septum.  Such  extensive  ulcers  cause  later  on  sinking-in 
of  the  bridge  of  the  nose,  which  never  follows  non- 
syphilitic  ulceration.  On  the  other  hand,  syphilitic 
ulceration  is  rapidly  controlled  by  thorough  specific  and 
proper  local  treatment.  (Compare  Figs,  i  and  2,  Plate  I.) 

HEMATOMA   AND  ABSCESS  OF  THE  SEPTUM. 

79-  A  very  rare  occurrence,  almost  invariably  of 
traumatic  origin, — hematoma, — is  an  effusion  of  blood 
under  the  perichondrium  of  the  cartilaginous  septum. 
It  occludes  the  nose  and  appears  as  a  soft  swelling  on  the 
septum.  It  rarely  imdergoes  absorption.  As  a  rule,  it 
lasts  a  number  of  days  and  then  changes  into  an  abscess 
which  may  bulge  on  either  side  or  on  both  sides  of  the  sep- 


l66  MEMBRANOUS   ANE    DIPHTHERITIC   RHINITIS. 

turn.  This  usually  causes  some  pain  and  headache.  It 
is  very  slow  to  open  spontaneously.  When  opened  widely 
with  the  knife,  it  heals  uneventfully.  Even  if  the  cartil- 
age has  been  perforated  by  the  suppurative  inflammation, 
no  unpleasant  results  are  apt  to  follow  after  the  healing. 

MEMBRANOUS  RHINITIS.     DIPHTHERITIC   RHINITIS. 

80.  Inflammation  of  the  nasal  mucous  lining,  with 
formation  of  false  membranes,  occurs  under  various  con- 
ditions and  from  different  causes.  It  is  occasionally 
observed  after  extensive  cauterization,  especially  surface 
cauterizations,  and  in  such  cases  is  a  strictly  localized 
process.  There  is  but  little  annoyance  beyond  slight 
soreness  and  obstruction  and  perhaps  moderate  bleeding. 
The  grayish  membranes  are  not  detached  easily,  and 
when  removed,  leave  a  denuded  surface  on  which  they 
form  again  within  some  hours.  It  is  due  to  infection  by 
the  streptococcus,  rareh'  the  staphylococcus,  but  always 
follows  a  benign  course,  although  it  may  last  two  to 
three  weeks. 

A  more  diffuse,  and  hence  more  annoying,  membranous 
rhinitis  occurs,  rarely  spontaneously,  not  uncommonly, 
however,  after  scarlet  fever.  This,  too,  is  due  to  the 
streptococcus,  yet  it  is  only  of  local  importance  and 
causes  no  systemic  disturbance.  Like  all  nasal  inflam- 
mations, it  threatens  the  ear. 

81.  Indistinguishable  in  its  appearance  from  strepto- 
coccus infection  is  true  diphtheritic  rhinitis.  It  causes 
similar  grayish  false  membranes  on  a  denuded  bleeding 
surface,  with  rapid  regeneration  of  the  membranes  after 
their  detachment.  The  process  is  sometimes  so  super- 
ficial that  it  may  be  termed  croupous,  while  in  other 
cases  it  involves  the  depth  of  the  mucous  lining,  as  in 
typical  diphtheria.  Yet  the  disease  is  of  a  benign  nature 
as  long  as  it  is  limited  to  the  nose,  and  it  causes  no 
systemic  infection  or  sequels.  The  diagnosis  of  its  diph- 
theritic nature  must  be  based  upon  finding  the  bacillus 
of  diphtheria  by  the  microscope  or  by  culture.     Its  grave 


TREATMENT.  1 67 

importance  is  its  contagiousness,  all  the  more  so  as  the 
patient  is  scarcely  sick.  Even  after  the  membranous 
formation  has  ceased  the  diphtheria  bacilli  persist  in  the 
nose  for  weeks.  Some  of  the  accessory  cavities  are  prob- 
ably always  involved  in  the  process,  harboring  the  specific 
bacteria,  even  if  there  be  no  membranous  inflammation 
in  the  sinus.  It  is  not  known  why  diphtheria  limited  to 
the  nasal  lining  has  none  of  the  malignancy  character- 
istic of  that  disease  in  other  localities. 

82.  The  treatment  of  membranous  rhinitis  must  de- 
pend upon  the  diagnosis  of  the  parasite  causing  it. 
Diphtheria  patients  must  be  isolated,  even  for  some  time 
after  recovery.  Antitoxin  should  be  invariably  employed 
within  the  first  three  or  four  days  of  the  disease.  If  of 
longer  duration,  it  is  doubtful  whether  the  specific  treat- 
ment has  any  influence  upon  it.  In  either  diphtheritic  or 
streptococcus  rhinitis  the  membrane  should  be  detached 
gently  with  forceps  as  far  as  it  can  be  done  without 
causing  bleeding.  No  one  has  recorded  a  sufficient  ex- 
perience to  formulate  any  rules  for  medicinal  treatment. 
It  is  desirable  to  check  secondary  bacterial  decomposi- 
tion, but  active  germicides  are  not  tolerated  well  by  the 
nasal  lining.  Sprays  of  essential  oils  in  watery  solution 
(1  25)  are  of  some  service  if  used  at  very  short  intervals, 
lyoffler's  solution  (compare  t  25),  while  momentarily  very 
irritant,  can  be  used  (after  cocain  spray),  but  its  efficacy 
has  not  been  sufficiently  tested. 

Much  more  serious  is  nasal  diphtheria  when  com- 
plicating and  secondary  to  diphtheria  of  the  pharynx. 
Under  these  circumstances  it  constitutes  one  of  the  most 
serious  manifestations  of  diphtheria,  a  great  menace  to 
life  and  always  a  danger  to  the  ear.  Yet  it  is  amenable 
to  the  specific  antitoxin  treatment  if  resorted  to  at  once. 
It  is,  however,  mostly  in  neglected  cases  of  throat  diph- 
theria that  the  extension  into  the  nose  occurs.  This 
complication  always  involves  a  very  long  course — up  to 
many  weeks  if  not  treated  specifically  at  the  beginning. 
Further  details  will  be  given  in  Chapter  XXIV. 


CHAPTER   XI. 

ENLARGEMENT    OF    THE     CAVERNOUS    TISSUE. 
(IRRITABLE   NOSE— CORYZA   VASOMOTORIA.) 

83.  Enlargement  of  the  venous  plexus,  with  increased 
vascular  irritability,  is  a  lesion  associated  with  various 
nasal  aflfections,  but  one  which  may  also  occur  as  a 
sequel  without  persisting  coexistence  of  other  nasal  dis- 
ease. As  certain  characteristic  nasal  symptoms  depend 
directly  upon  this  condition,  it  deserves  special  descrip- 
tion. 

The  entire  nasophar\'ngeal  mucous  membrane  is  highly 
vascular,  with  a  decided  preponderance  of  veins  in  the 
deeper  layer.  Around  the  anterior  end  of  the  inferior 
turbinal,  and  to  a  less  extent  around  the  posterior  ends  of 
both  inferior  and  middle  turbinals,  the  venous  plexus  in 
the  mucous  membrane  is  massed  so  as  to  form  a  distinct 
vascular  cushion  capable  of  turgescence  (see  Figs.  8, 
9,  and  10).  Normally,  the  mucous  membrane  ap- 
pears slightly  compressible  over  these  areas,  showing 
the  normal  distention  of  the  vessels  by  blood.  Un- 
doubtedly moderate  variations  in  the  vascularity  occur 
during  the  normal  condition,  but  are  not  so  demonstrable 
as  when  the  cavernous  tissue  is  increased.  Even  in  a 
normal  nose  a  visible  vascular  constriction  is  produced 
in  these  localities  by  the  application  of  cocain  or  supra- 
renal solution.  But  when  the  cavernous  tissue  is  mor- 
bidly augmented,  the  changes  in  its  turgescence  are  very 
striking.  Under  the  influence  of  fright  or  syncope,  or 
upon  the  application  of  cocain,  the  previously  swollen 
mucous  membrane  shrinks  visibly — though  without 
change  of  color — until  it  lines  the  bony  contour  accu- 
rately. As  the  result  of  various  modes  of  irritation  the 
vascular  swelling  may,  on  the  other  hand,  become  so  ex- 

IfiS 


ENLARGEMENT    OF    THE    CAVERNOUS    TISSUE.  1 69 

tensive  as  to  occlude  the  passages  entirely.  The  course 
of  the  nerves — presumably  both  vasoconstrictor  and  vaso- 
dilator fibers — which  control  these  blood-vessels  is  not 
known. 

The  turgescent  area  at  the  front  part  of  the  inferior 
turbinal  slopes  so  gradually  toward  the  rear  that  its  limits 
cannot  be  defined,  especially  as  the  vascular  network 
throughout  the  entire  mucous  membrane  over  the  turbi- 
nals  differs  from  pronounced  cavernous  tissue  only  in 
degree.  The  cavernous  cushions  on  the  posterior  ends 
of  inferior  and  middle  turbinals  are  more  circumscribed. 
Their  normal  pale  yellowish-pink  color  changes  into  a 
violet-pink  hue  when  their  turgescence  makes  them 
appear  as  globular  tumors  occluding  the  posterior  choanse 
in  the  postrhinoscopic  image.  As  the  result  of  disease, 
vascular  cushions  are  sometimes  developed  in  localities 
where  there  is  normally  no  cavernous  tissue — viz.,  ante- 
riorly over  the  tuberculum  septi,  sometimes  on  the  floor 
of  the  inferior  meatus,  or  as  part  of  a  hypertrophic  pro- 
tuberance on  the  septum  next  to  its  posterior  edge. 

Every  acute  inflammatory  attack  is  accompanied  by 
engorgement  of  the  cavernous  plexus.  While  a  single 
transient  coryza  leaves  no  gross  change,  repeated  or  pro- 
longed attacks  may  lead  to  permanent  enlargement  of  the 
cavernous  tissue.  Whether  this  hypertrophy  differs  from 
the  original  normal  structure  histologically  has  not  been 
studied  fully.  A  condition  which  is  of  marked  deter- 
mining influence  by  favoring  the  augmentation  of  the 
vascular  structure  is  the  existence  of  septum  irregu- 
larities. It  is,  however,  not  the  extensive  deflections  or 
thick  prominences  causing  continuous  stenosis  which 
lead  to  vascular  hypertrophy,  but  rather  small  spurs  and 
crests  which  do  not  perceptibly  narrow  the  passage  except 
while  there  is  vascular  engorgement.  The  larger  septum 
irregularities  in  connection  with  any  persistent  inflam- 
mation favor  hypertrophy  of  the  entire  mucous  mem- 
brane, which  becomes  most  redundant  on  the  (roomier) 
side  of  the  septum  concavity. 


I/O  ENLARGEMENT    OF   THE    CAVERNOUS    TISSUE. 

Purely  vascular  enlargement  is  readily  distinguished 
from  hyperplasia  of  the  entire  membrane.  In  the  former 
case  the  swelling  can  be  indented  with  the  probe  and 
disappears  completely  when  cocainized.  An  excised  bit 
of  mucous  membrane  shows  normal  thickness.  In  the 
latter  case  the  probe  recognizes  the  excessive  thickness 
of  the  lining  membrane,  which  an  excision  confirms, 
while  after  cocain  the  membrane  covering  the  bone, 
although  somewhat  reduced,  still  shows  a  distinct  aug- 
mentation of  volume  as  compared  with  the  normal. 
Vascular  enlargement  and  actual  hyperplasia  may  be 
combined  to  a  moderate  extent,  but  any  extensive  hyper- 
trophy of  the  mucous  membrane  as  a  whole  excludes 
overdevelopment  of  the  venous  plexus. 

84.  In  subjects  giving  the  history  of  frequent,  though 
transient,  attacks  of  coryza  and  presenting  some  slight 
surface  irregularity  of  the  septum,  permanent  enlarge- 
ment of  the  cavernous  tissue  without  any  coexisting 
inflammatory  lesion  is  occasionally  observed.  Women 
are  more  liable  to  it  than  men.  It  is  not  common  in 
children.  Closer  inquiry  always  reveals  in  these  patients 
a  neurotic  condition,  sometimes  neurasthenia,  often 
hysteria,  sometimes  mere  '*  nervousness, "  but  always 
exalted  excitability  of  the  nervous  system.  Quite  often, 
too,  the  history  proves  that  intestinal  disturbances, 
especially  constipation,  have  been  of  etiologic  influence. 

More  frequently  than  as  an  isolated  condition  vascular 
overdevelopment  is  found  in  association  with  other  irri- 
tative nasal  diseases,  such  as  suppuration  of  the  nasal 
passages  or  accessory  cavities,  polypi,  or  hypertrophic 
rhinitis  in  its  earlier  stages.  Under  these  circumstances, 
too,  the  vascular  irritability  is  a  mirror  of  the  instability 
of  the  nervous  system  of  the  individual.  Female  patients 
preponderate  decidedly.  Massive  diffuse  hypertrophy  of 
the  mucous  membrane,  on  the  other  hand,  limits  the 
development  of  cavernous  tissue;  advanced  atrophic  rhi- 
nitis excludes  it. 

85.  The    complaints    are    partly   mechanical,    partly 


SYMPTOMS.  1 7 1 

nervous  symptoms.  In  spite  of  considerable  enlarge- 
ment of  cavernous  tissue  the  passages  may  be  clear  a 
variable  part  of  the  time.  But  in  the  recumbent  posi- 
tion, especially  during  sleep,  engorgement  occurs  in  the 
nostril  on  the  lower  side  of  the  head,  causing  occlusion 
of  the  passage.  The  slight  difference  in  the  venous 
blood  pressure  produced  by  turning  the  head  on  the  other 
side  suffices  to  transfer  the  engorgement  to  the  other  side, 
allowing  the  first  affected  nostril  to  clear  in  the  course 
of  a  few  minutes.  Very  striking  is  the  alternating  uni- 
laterality  of  the  turgescence.  Except  during  acute  in- 
flammation or  in  very  irritable  subjects  with  one-sided 
stenosis,  one  side  of  the  nose  is,  as  a  rule,  clear.  The 
same  one-sided  engorgement  can  occur  in  consequence  of 
drafts,  dust,  or  irritating  gases  and  smells.  The  occlud- 
ing vascular  turgescence  is  seen  on  inspection  anteriorly. 
In  some  instances  a  similar  but  more  localized  engorge- 
ment is  found  at  the  posterior  end  of  one  or  both  turbinals 
on  examination.  The  swelling  may  subside  in  a  short 
time,  or  under  conditions  of  irritation  may  alternate  be- 
tween the  two  sides  for  a  longer  period.  Cocain  or  supra- 
renal solution  reduces  it  at  once.     (Comp.  Fig.  3,  Plate  I.) 

86.  In  nervous  subjects  the  vascular  dilatation  may 
lead  to  other  symptoms.  A  sneezing  fit,  sometimes 
lasting  to  a  distressing  extent,  with  watery  secretion, 
tearing  and  redness  of  the  eyes,  and  finally  total  nasal 
occlusion,  at  least  one-sided,  constitute  the  attacks  of 
so-called  vasomotor  coryza  or  irritable  nose.  Their  fre- 
quency depends  very  much  on  the  nervous  condition  of 
the  patient  and  on  the  opportunities  for  irritation. 

Some  patients  possess  an  idiosyncrasy  in  regard  to 
certain  odors  or  irritants  which  give  them  always  a 
severe  fit  of  vasomotor  coryza.  Such  irritants  are  ipecac, 
the  odor  of  roses,  and  perhaps  more  frequently  the  smell 
of  horses.  The  attacks  may  pass  off  in  a  fraction  of  an 
hour,  or,  when  severe,  may  last  many  hours.  These 
fugitive  attacks,  resembling  a  true  coryza  in  their  sub- 
jective symptoms,  have  led  to  much  confusion  in  litera- 


172  ENLARGEMENT   OF   THE    CAVERNOUS   TISSUE. 

ture,  and  account  for  the  many  erroneous  reports  con- 
cerning the  abortive  treatment  of  "  colds."  It  is  singular 
that  the  sneezing  fits  and  attacks  of  vasomotor  coryza 
cease  entirely  during  the  course  of  any  severe  general 
disease.  The  astute  observer,  Jonathan  Hutchinson,  has 
asked  pointedly,  '*Who  has  ever  heard  a  sick  man 
sneeze?"  In  markedly  neurotic  subjects  these  spells 
may  be  followed  occasionally  by  fugitive  edema  (urtica- 
ria) of  the  eyelids,  conjunctiva  of  the  eyeball,  or  skin  of 
the  face  next  to  the  nose.  Attacks  of  vasomotor  coryza 
may  likewise  lead  to  scotoma  scintillans  with  headache, 
dizziness,  or  more  generally  a  feeling  of  confusion  or  an 
attack  of  asthma,  sometimes  a  prolonged  fit  of  coughing 
(compare  Chapter  XXIX.).  The  results  of  local  treat- 
ment show  that  these  nervous  phenomena  depend  on  the 
turgescence  in  the  anterior  parts,  rather  than  on  the  en- 
gorgement of  the  rear  end  of  the  turbinals. 

87.  Treatment  must  begin  with  the  search  for  any  local 
irritative  lesions.  The  removal  of  a  small  hidden  poly- 
pus may  end  all  trouble.  Proper  cauterization  of  an 
inflamed  or  granulating  area,  successful  drainage  of  a 
suppurating  sinus  or  a  cyst  in  the  maxillary  sinus,  may 
effect  a  cure.  Very  rarely  a  fissure  in  the  vestibule  keeps 
the  nose  irritable.  The  removal  of  spurs  and  ledges  on 
the  septum  (see  Chapter  XVI.)  is  often  an  indispensable 
step  for  success,  but  may  not  be  followed  by  a  speedy 
cessation  of  the  irritability — indeed,  may  prove  insuffi- 
cient, if  not  accompanied  by  cauterization  of  the  cavern- 
ous tissue.  If  removal  of  the  presumable  irritative  lesion 
fails  to  cure  the  irritability,  or  in  case  no  other  lesion  can 
be  found,  the  vascular  engorgement  and  irritability  can 
be  permanently  stopped  by  thorough  destruction  of  the 
cavernous  tissue.  When  there  is  only  vascular  enlarge- 
ment without  hypertrophy  of  the  mucous  membrane,  the 
swelling  cannot  be  thoroughly  taken  away  with  the 
snare.  Cauterization  with  trichloracetic  acid  or  superfi- 
cial cauterization  with  the  galvanocautery  gives  relief, 
but  no  permanent  results.     The  only  radical  way  is  deep 


TREATMENT.  1/3 

cauterization  by  multiple  punctures  (1  27),  one  side  at  a 
time,  followed  two  to  three  weeks  later  by  the  same 
operation  on  the  other  side.  The  case  should  then  remain 
under  observation  for  many  weeks,  and  whenever  return- 
ing symptoms  and  repeated  examination  show  the  vascu- 
lar areas  still  capable  of  engorgement,  these  should  be  suc- 
cessively destroyed.  It  is  very  rarely  necessary  to  operate 
on  the  posterior  ends  of  the  turbinals.  By  these  means, 
persistently  pursued,  a  permanent  cure  can  be  obtained. 
Cases  complaining  only  of  mechanical  obstruction  are 
much  more  readily  controlled  than  the  nervous  phe- 
nomena of  neurotic  patients.  The  relief  from  insufficient 
operations  may  gradually  disappear,  and  a  relapse  may 
occur,  since  the  remnants  of  cavernous  tissue  regenerate 
readily  under  the  stimulus  of  acute  inflammations  or  per- 
sistent irritation. 

Cauterization  can  be  dispensed  with  or  deferred  in 
those  patients  whose  complaints  depend  on  some  nervous 
condition  of  transient  or  controllable  nature.  The  nervous 
nasal  symptoms  are,  for  instance,  apt  to  be  exaggerated 
during  a  pregnancy,  to  subside  again  later  on.  As  there 
are  some  instances  of  miscarriage  on  record,  attributable 
to  cauterization,  discretion  should  be  exercised.  A  pa- 
tient run  down  by  overwork,  anxiety,  or  loss  of  sleep 
may  become  comfortable  by  proper  hygienic  management 
without  local  treatment.  The  injurious  influence  of 
digestive  disturbances  upon  the  nose  must  not  be  over- 
looked. Relief  may  be  obtained  by  avoiding  hitherto 
disregarded  exposure  to  dust.  A  trip  to  the  mountains 
or  to  any  dustless  locality  with  mild  climate  is  apt  to 
give  at  least  temporary  benefit. 


CHAPTER   XII. 

RETRONASAL  CATARRH. 

88.  Retronasal  catarrh  is  characterized  by  a  mucous 
secretion  in  the  posterior  part  of  the  nose,  with  absence 
of  all  gross  lesions.  The  disease — the  most  frequent 
of  all  nasal  affections  in  the  United  States — is  not  cor- 
rectly described  in  most  text-books,  and  is  generally 
confused  more  or  less  with  hypertrophic  rhinitis.  While, 
indeed,  it  is  often  associated  with  other  forms  of  nasal 
disease,  it  occurs  in  the  uncomplicated  form  sufficiently 
often  to  justify  its  recognition  as  a  disease  entity. 

The  only  symptom  is  the  secretion  of  mucus  dropping 
into  the  pharynx.  The  mucus  is  tliick,  usually  some- 
what inspissated,  foamy  from  air-bubbles,  and  in  cities  is 
stained  grayish  dark  by  soot  and  dust.  While  containing 
a  few  round  cells  microscopically,  it  is  not  at  all  purulent. 
From  the  posterior  parts  of  the  nose  it  flows  into  the 
pharynx,  to  be  swallowed  or  spat  out.  When  very  viscid, 
it  adheres  to  the  posterior  surface  of  the  soft  palate  and  is 
removed  by  the  familiar  guttural  gurgling  sound  of  hawk- 
ing, which  throws  the  palate  into  vibration.  When  very 
abundant,  the  patient  occasional!}^  draws  it  into  the 
pharymx  by  a  strong  nasal  inspiration,  as  he  cannot 
expel  it  forward.  The  discharge  is  not  identical  with 
pus  formed  at  the  roof  of  the  phar\'nx  in  inflammation 
localized  at  that  spot.  In  a  normal  nose  there  is  no 
secretion  whatsoever,  sufficient  to  flow  or  to  collect, 
except  momentarily  in  consequence  of  external  irrita- 
tion. 

89.  In  uncomplicated  retronasal  catarrh  no  gross  lesions 
whatsoever  can  be  detected  in  the  nose  or  nasophar^-nx. 
Such  uncomplicated  cases  are  more  common  among  fe- 
males than  males.     More  frequently,  however,  retronasal 

174 


RETRONASAL    CATARRH.  1/5 

catarrh  is  associated  with  hypertrophic  rhinitis,  some- 
times with  other  nasal  lesions.  We  may  thus  find  sep- 
tum deformities  and  thickening,  diflfuse  localized  hyper- 
trophy of  mucous  membrane  on  the  turbinals,  enlargement 
of  cavernous  tissue,  and  hyperplasia  of  the  various  areas 
of  pharyngeal  adenoid  tissue.  But  none  of  the  lesions 
are  constant  or  essential.  The  amount  and  viscidity  of 
secretion  are,  however,  very  much  influenced  by  any 
interference  with  the  patency  of  the  nasal  passages.  The 
disease  is  relatively  rare  in  subjects  with  wide  passages, 
while  the  annoyance  from  the  "sticky"  discharge  in- 
creases with  the  degree  of  nasal  stenosis.  Any  obstructing 
lesion,  even  transient  enlargement  of  the  cavernous  tis- 
sue, is  thus  an  aggravating  factor  in  the  disease. 

90.  The  disease,  almost  unknown  under  the  age  of 
puberty,  is  common  only  after  adolescence,  being  more 
frequent — at  least  in  its  associated  form — in  the  male. 
Every-day  observation  shows  its  extreme  distribution, 
as  judged  by  the  characteristic  hawking  noise  wherever 
people  meet.  On  account  of  the  slight  annoyance  and 
the  absence  of  sequels,  patients  with  the  pure  type  of  the 
disease  do  not  commonly  seek  treatment.  The  disease 
usually  lasts  indefinitely,  improving  in  mild  weather, 
but  rarely  disappearing  entirely,  except  under  improved 
climatic  environment. 

It  is  of  inflammatory  origin,  as  can  be  learned  in  those 
rare  cases  which  seek  advice  at  the  beginning.  It  is 
temporarily  aggravated  by  every  fresh  coryza.  In'  the 
absence  of  lesions  visible  during  life  and  in  default  of 
autopsies  we  can  only  infer  that  it  consists  in  a  low  grade 
of  superficial  inflammation  localized  in  the  posterior 
region  of  the  nose. 

91.  There  is  no  treatment  known  which  can  directly 
cure  a  retronasal  catarrh  and  stop  the  dropping  of  mucus. 
In  the  rare  instances  of  retronasal  catarrh  with  normal 
caliber  of  passage, — which  we  do  not  see  often,  since  such 
patients  are  so  little  annoyed, — local  applications  of  any 
kind  have  proved  useless.     I  base  this  opinion  fully  as 


1/6  RETRONASAL    CATARRH. 

much  on  the  history  of  patients  treated  by  others  as  on 
my  own  negative  results.  At  the  most  we  can  give  some 
palliating  advice  regarding  moderation  in  smoking, 
proper  diet,  if  required,  and  attention  to  the  state  of  the 
bowels.  But  in  the  majority  of  cases  which  call  for  treat- 
ment, complicating  and  prejudicial  lesions  are  found 
that  can  be  removed  with  decided  improvement  in  the 
patient's  comfort,  though  without  curing  the  retronasal 
hypersecretion  in  the  strict  sense  of  the  word.  Operations 
upon  existing  septum  deformities,  the  snaring  of  mucous 
tissue  hypertrophies,  the  cauterization  of  excessive  cavern- 
ous tissue,  if  judiciously,  done,  usually  give  the  patient 
subjective  satisfaction. 


CHAPTER  XIII. 

SIMPLE    CHRONIC    RHINITIS— HYPERTROPHIC 
RHINITIS. 

93.  Next  to  retronasal  catarrh,  chronic  or  hypertrophic 
rhinitis  is  the  most  common  nasal  disease  in  our  climate. 
It  is  a  chronic,  more  or  less  diffuse,  inflammation  of 
the  nasal  mucous  membrane,  which  ultimately  leads  to 
generalized  or  circumscribed  hypertrophy.  There  is, 
hence,  no  sharp  distinction  between  simple  chronic  and 
hypertrophic  rhinitis.  The  symptoms  are  those  common 
to  all  chronic  nasal  affections  and  are  not  characteristic  of 
it.  Indeed,  there  may  be  total  absence  of  all  symptoms. 
It  is  always  associated  with  some  enlargement  of  the  cav- 
ernous tissue  during  its  earlier  stage.  Hence  a  variable 
amount  of  intranasal  turgescence  is  one  of  its  features. 
Later  on,  however,  when  the  stage  of  massive  hypertro- 
phy of  mucous  membrane  has  been  reached,  the  vascular 
enlargement  and  its  variable  engorgement  become  of 
minor  importance.  The  amount  of  nasal  obstruction 
caused  by  the  cavernous  engorgement,  and  later  on  by 
the  permanent  thickening  of  the  mucous  lining,  depends 
upon  the  original  width  of  the  nasal  passage.  The  nar- 
rower the  passage,  or  the  more  encroachment  by  any  cir- 
cumscribed hypertrophy,  the  more  distressing  becomes 
the  interference  with  nasal  breathing.  In  extreme  in- 
stances both  sides  may  be  permanently  insufficient  for 
the  passage  of  air.  Such  excessive  nasal  obstruction 
gives  rise  often  to  a  feeling  of  oppression  in  the  head, 
and  may  cause  irregular  dull  headache  in  neurotic  sub- 
jects. Insufficient  nasal  caliber  necessarily  causes  mouth- 
breathing. 

There  is  no  discharge  peculiar  to  hypertrophic  rhinitis. 
When  not  associated  with  other  lesions,  especially  retro- 

12  177 


1/8    SIMPLE    CHRONIC    RHINITIS— HYPERTROPHIC    RHINITIS. 

nasal  catarrh,  there  is  no  discharge  whatsoever.  Usually 
the  mucous  membrane  is  irritable  and  starts  a  watery 
flow  upon  irritation  by  dust  or  from  turgescence  due  to 
drafts.  When  a  purulent  rhinitis  coexists  with  it,  the 
pus  present  is  due  to  that  complication.  When  there  is 
much  diffuse  hypertrophy,  the  sense  of  smell  is  often 
interfered  with. 

Chronic  rhinitis  does  not  pursue  a  uniform  course,  but 
is  intensified  by  every  acute  attack,  and  may  become 
nearly  latent  under  favorable  surroundings.  It  rarely 
ceases  permanently  in  our  climate.  It  may  come  to  a 
standstill  in  more  favorable  localities.  Any  existing 
hypertrophies,  however,  persist. 

93*  While  this  disease  may  present  few  or  no  symptoms, 
its  importance  depends  on  its  possible  complications. 
These  are  stricture  of  the  lachrymal  duct,  chronic  con- 
junctivitis, occasionally  marked  irritability  of  the  eyes, 
causing  asthenopia,  hypertrophy  of  the  various  pharyngeal 
structures,  among  which  chronic  disease  of  the  lingual 
tonsil  is  the  most  distressing.  The  disease,  furthermore, 
predisposes  to  laryngitis  and  to  bronchitis.  Its  most 
serious  a.spect,  however,  is  the  liability  to  extend  through 
the  Eustachian  tube,  causing  a  hyperplastic  process  in 
that  passage  and  in  the  middle  ear. 

94.  On  inspection  the  mucous  membrane  is  found 
more  or  less  injected.  This  morbid  redness  may  dimin- 
ish under  favorable  influences  until  the  normal  pallor  is 
attained.  With  every  acute  coryza,  however,  the  injec- 
tion returns  and  persists  for  a  while.  After  the  disease 
has  led  to  hypertrophy  of  the  lining  membrane,  the 
acute  inflammatory  attacks  are  apt  to  be  milder  and  of 
more  transient  character  than  in  normal  nasal  passages, 
but,  on  the  other  hand,  they  occur  oftener  and  always 
prove  more  persistent  in  the  end. 

Diff'use  hypertrophy  of  the  mucous  membrane  is  recog- 
nizable only  when  it  has  reached  a  high  degree,  and  can 
be  best  observed  where  the  lining  passes  over  some  promi- 
nence of  the  bony  or  cartilaginous  frame.   The  thickened 


SYMPTOMS. 


179 


membrane  is  often  roughened  or  corrugated.  On  the 
surface  of  the  septum  the  normally  minute  ridges  are 
exaggerated.  The  inferior  turbinal  often  presents  papil- 
lary elevations,  especially  in  the  middle  and  rear  regions. 
Even  when  the  thickening  is  not  apparent  to  the  eye, 
the  microscope  shows  in  excised  fragments  inflammatory 
round-cell  infiltration  with  some  increase  of  connective 


Fig.  50. — Polypoid  degeneration  of  the  mucous  membrane  over  the  inferior 
turbinal  (Zuckerkandl). 


tissue.     The  ciliated  epithelium  is  partly  changed  into 
cuboid  cells  and  often  increased  in  thickness. 

Circumscribed  hypertrophies  can  be  more  easily  recog- 
nized. They  may  be  limited  to  but  a  single  locality,  or 
may  occur  in  combination.  Occasionally  every  one  of 
the  types  to  be  described  is  found  present.  On  the  in- 
ferior turbinal  the  mucous  membrane  is  distinctly  thick- 
ened, sometimes  forming  a  flabby,  pendant  overgrowth. 
Unlike  the  pure  hypertrophy  of  the  venous  plexus  this 


l80   SIMPLE    CHRONIC    RHINITIS — HYPERTROPHIC    RHINITIS, 

mucous  membrane  hypertrophy  does  not  shrink  much 
under  the  influence  of  cocain  or  suprarenal  solution. 
When  the  veins  have  retracted  under  the  influence  of 
these  agents,  the  thickened  mucous  membrane  can  still 
be  lifted  at  the  free  border  of  the  turbinal  by  the  probe. 
This  thickening  may  be  limited  to  the  anterior  end  or 
may  extend  over  the  entire  length  of  the  inferior  turbinal 
(Fig.  50).  A  well-defined  hypertrophy  is  always  found 
at  the  front  end  of  the  inferior  turbinal  on  the  concave 
(roomy)  side  of  the  nose  in  case  of  any  marked  septum 
deflection.  A  similar  lesion  is  .  found  less  often  at  the 
front  end  of  the  middle  turbinal.     Here  the  redundant 


Fig.  51. — Postrhinoscopic  view  of  hypertrophy  of  inferior  and  middle  turbinals. 

mucous  membrane  may  hang  down  so  as  to  resemble  a 
polypus.  True  polypi,  however,  have  a  distinctly  con- 
stricted pedicle.  Circumscribed  hypertrophies  may  be 
found  at  the  rear  ends  of  inferior  and  middle  turbinals. 
In  the  postrhinoscopic  mirror  they  are  seen  in  the  form 
of  semiglobular  tumors  filling  and  even  occluding  the 
posterior  choanae.  Their  surface  is  sometimes  smooth, 
more  often  wart-like  (Fig.  51).  When  these  growths 
consist  of  cavernous  tissue  exclusively,  they  are  of  pur- 
plish hue  and  disappear  entirely  when  cocainized.  But 
the  more  hypertrophic  mucous  membrane  they  contain, 
the  more  gelatinous  and  grayish  is  their  appearance,  and 
such  overgrowths  retract  onlv  to  a  slisrht  extent  under 


SYMPTOMS.  I  8 1 

cocain.  These  lesions  can,  of  course,  be  observed  in  the 
living  only  by  means  of  the  postrhinoscopic  mirror. 
(Compare  Figs.  3  and  4,  Plate  I.) 

Deviation  of  the  septum  from  the  median  line  is  an 
important  predisposing  condition,  and  hence  often  found 
in  hypertrophic  rhinitis.  The  disease  itself,  however, 
leads  to  deformity  of  the  septum  by  producing  lateral 
crests,  ridges,  and  spurs.  The  detailed  description  of 
these  hypertrophic  lesions  of  the  septum  will  be  given 
in  Chapter  XVI. 

A  septum  lesion  peculiar  to  hypertrophic  rhinitis  is 
the  cushion-like  prominence  seen  occasionally  in  the  post- 
rhinoscopic image  on  one  or  both  sides  of  the  septum,  ad- 
joining its  rear  edge.  This  is  a  hypertrophy  of  the  mucous 
membrane,  with  more  or  less  cavernous  tissue,  situated 


Fig.  52. — View  of  the  posterior  choanse  in  the  cadaver  from  the  rear,  showing 
polypoid  hypertrophies  on  both  sides  of  the  septum  (Zuckerkandl). 

often,  but  not  always,  over  a  spur  on  the  septum.  It 
appears  as  a  grayish  protuberance  when  seen  from  the 
rear,  and  is  somewhat  reducible  by  cocain  (Fig.   52). 

The  clinical  history  of  hypertrophic  rhinitis  is  not 
complete  without  reference  to  the  various  hypertrophies 
of  the  pharyngeal  adenoid  tissue  (tonsils)  which  com- 
monly occur  in  connection  with  it,  but  which  will  be 
separately  described  in  Chapters  XX.,  XXL,  and  XXII. 
In  fact,  in  most  cases  the  disease  might  be  called  rhino- 
pharyngitis, since  the  inflammatory  and  proliferative 
process  extends  throughout  the  entire  lining  of  nasal 
passages  and  pharynx. 

95.  Chronic  rhinitis  results  from  the  prolongation  of 
acute  coryza,    especially   when    this  occurs   in    frequent 


1 82    SIMPLE    CHRONIC    RHINITIS — HYPERTROPHIC    RHINITIS. 

attacks.  It  is  aggravated  by  every  fresh  coryza.  A  per- 
sistence of  the  inflammation  seems  to  depend  largely  on 
any  structural  peculiarities  narrowing  the  nasal  passage. 
While  localized  projections  which  dam  up  pus  help  to 
perpetuate  a  chronic  purulent  rhinitis,  any  diffuse  form 
of  stenosis,  on  the  other  hand,  favors  the  occurrence  of 
hypertrophic  rhinitis.  As  the  disease  itself  leads  to  further 
hypertrop^iies,  its  tendency  to  perpetuation  explains  itself 
It  is  uncommon  in  wide  passages,  and  much  less  common 
in  childhood  than  after  adolescence.  Its  occurrence  in 
children  is  favored  by  hypertrophy  of  the  pharyngeal  ton- 
sil. Unfavorable  hygienic  factors,  exposure  to  drafts  and 
insufficient  protection,  a  poor  cutaneous  circulation,  cold 
feet,  and  bowel  disturbances  predispose  to  it.  There  is 
no  reason  to  doubt  that,  like  most  forms  of  inflammation, 
it  is  directly  or  indirectly  dependent  on  parasitic  in- 
fluences. But  no  definite  form  of  bacteria  has  as  yet 
been  found  associated  with  it  in. various  researches.  The 
tendency  to  hypertrophy  is  evidently  an  individual  pe- 
culiarity of  which  we  do  not  know  the  conditions.  The 
disease  may  last  long  periods  of  time  with  scarcely  any 
hypertrophy  in  some  patients,  while  in  others  it  rapidly 
leads  to  the  lesions  described. 

96.  The  treatment  of  hypertrophic  rhinitis  aims  to  arrest 
the  disease  and  to  remove  surgically  any  enlargements 
which  exert  an  unfavorable  influence.  Since  the  chronic 
rhinitis  is  the  outcome  and  perpetuation  of  acute  inflam- 
mation and  becomes  intensified  by  every  acute  attack,  the 
hygienic  management  must  attempt  to  prevent  acute  and 
subacute  exacerbations.  Attention  must  be  paid  to  the 
general  health,  the  digestion,  the  state  of  the  bowels, 
the  peripheral  circulation  (cold  feet),  and  the  habits 
of  the  patient  (compare  %  16  and  1  17).  The  inflamma- 
tion itself  may  be  reduced  by  daily  treatment  with  the 
spray  of  essential  oils  in  watery  solution  (compare  Tf  25). 
Its  influence  is  augmented  by  previously  reducing  the 
nasal  turgescence  by  means  of  suprarenal  solution  in  the 
form  of  a  spray,  preferably  with  the  addition  of  cocain. 


TREATMENT.  1 83 

Under  no  circumstances,  however,  should  cocain  be  given 
to  the  patient  for  habitual  use.  The  douche  is  entirely 
uncalled  for  unless  the  disease  is  associated  with  purulent 
rhinitis.  Localized  areas  of  injected  mucous  membrane 
may  be  brushed  with  nitrate  of  silver  solution  (5  to  10 
per  cent),  but  diifuse  applications  of  this  agent,  as  well 
as  of  other  so-called  astringents, — tannin,  iodin  solutions, 
and  so  on, — have  generally  no  appreciable  influence.  In 
fact,  it  is  quite  questionable  whether  the  disease  can  be 
influenced  to  any  marked  extent  by  medicinal  applica- 
tions of  any  kind,  except  during  periods  of  subacute 
intensification. 

Decided  benefit  can  be  expected  from  surgical  pro- 
cedures directed  against  any  hypertrophies  of  sufficient 
extent  to  encroach  upon  the  caliber  of  the  passage.  As 
the  disease  itself  is  perpetuated  by  any  interference  with 
the  nasal  caliber,  such  surgical  procedures  influence  not 
merely  the  spot  against  which  they  are  directed,  but  the 
entire  disease.  Hence,  by  properly  restoring  the  patency 
of  the  nose,  we  can  practically  cure  all  manifestations  of 
the  disease  in  many  instances.  Relapses,  however,  must 
be  expected  under  unfavorable  environments. 

97.  Hypertrophies  of  the  mucous  membrane  over  the 
anterior  end  of  the  inferior  turbinal  are  removed  best  by 
means  of  the  cold  snare.  If  not  of  such  shape  that  they 
can  be  grasped  securely  by  the  loop,  they  are  first  to  be 
transfixed  with  a  needle,  over  which  the  loop  is  then 
placed.  There  is  but  slight  bleeding  at  the  time,  but  often 
enough  later  on  to  require  a  tampon  for  the  first  twenty- 
four  hours.  When  the  enlargement  consists  of  relatively 
much  cavernous  tissue  with  but  little  hypertrophy  of  mu- 
cous membrane,  the  snare  cannot  grasp  enough  after  the 
action  of  cocain.  Eucain  /9,  which  does  not  constrict 
the  blood-vessels,  is  more  applicable  in  such  a  case. 
When  snaring  is  not  feasible,  the  hypertrophy  may  be 
reduced  by  the  galvanocautery,  preferably  in  the  form  of 
multiple  punctures  without  needless  sacrifice  of  surface. 
A  burned  wound,  however,  is  always  more  unpleasant 


184   SIMPLE   CHRONIC    RHINITIS HYPERTROPHIC    RHINITIS, 

and  requires  a  longer  time  to  heal  than  a  clean  cut.  In 
the  case  of  extensive  diffuse  hypertrophy  of  the  entire 
mucous  membrane  over  the  inferior  turbinated  bone  in  a 
narrow  nasal  passage,  the  most  satisfactory  operation  is 
partial  removal  of  this  process,  including  the  bone.  This 
operation,  called  turbinectomy,  lately  much  favored  in 
England,  is  quite  useful  when  properly  indicated — in 
other  words,  when  stenosis  is  due  to  the  prominence  of  a 
projecting  hypertrophied  inferior  turbinated  bone.  In 
any  other  case  it  is  a  needless  mutilation.  The  projecting 
part  of  the  process  can  be  cut  off  by  suitable  slender  cut- 
ting forceps,  or  even  by  the  wire  snare  after  notching 
the  free  border  toward  the  rear  with  the  galvanocaustic 
burner,  in  order  to  insert  the  snare.  It  may  be  also  am- 
putated easily  by  means  of  a  small  sharp  saw. 

Overgrowth  of  the  mucous  membrane  at  the  front  end 
of  the  middle  turbinal  requires  removal  by  snaring  only 
when  sufficiently  pendant  to  be  easily  grasped  by  the 
snare. 

Hypertrophies  of  the  rear  ends  of  inferior  and  middle 
turbinals  require  removal  whenever  they  can  be  seen  in 
the  postnasal  mirror  as  distinct  encroachments  upon  the 
space.  These  are,  however,  difficult  operations.  The 
most  satisfactory  instrument  is  the  cold  snare.  When 
the  operator  feels  that  the  loop  inserted  through  the  ante- 
rior nares  has  grasped  a  resisting  projection,  its  position 
should  be  verified  by  the  use  of  the  postnasal  mirror,  or 
by  the  finger  in  the  pharynx.  The  loop  may  have  to  be 
variously  shaped  and  bent  before  it  will  catch.  On  ac- 
count of  the  probability  of  bleeding,  it  is  best  to  tighten 
the  wire  very  slowly,  and  even  then  the  operator  must  be 
prepared  to  plug  the  postnasal  space  (compare  1  29)  if 
tampons  wound  on  tooth-picks  do  not  control  the  bleed- 
ing. When  the  wire  loop  cannot  be  applied  successfully, 
it  will  sometimes  slip  easier  into  grooves  burned  into  the 
turbinals.  For  this  purpose  a  suitably  shaped  bent 
burner  can  be  inserted  through  the  nose,  while  its  posi- 
tion is  watched  in  the  postnasal  mirror.     Usually  retrac- 


TREATMENT.  1 85 

tion  of  the  soft  palate  by  the  hook  or  rubber  band  is 
required  for  this  purpose.  After  the  burner  has  been 
suitably  placed,  the  mirror  may  be  withdrawn  and  the 
cautery  handle  is  now  brought  into  contact  with  the 
burner  meanwhile  held  by  the  finger.  With  a  slight 
withdrawing  movement  a  groove  can  thus  be  burned.  In 
the  case  of  very  vascular  tumefactions  which  retract  under 
cocain  or  even  in  consequence  of  the  patient's  anxiety,  so 
that  they  elude  the  snare,  their  obliteration  can  be  ac- 
complished only  by  the  galvanocaustic  burner  under  the 
guidance  of  the  mirror.  Very  suitable  double-jointed 
scissors  have  lately  been  devised  by  Fein  (Fig.  53).  As 
they  are  sure  to  catch  the  projecting  hypertrophy,  it  can 


Fig.  53. — Fein's  scissors  for  the  removal  of  the  posterior  ends  of  the  inferior 

turbinal. 

be  cut  off  promptly.  A  free  hemorrhage,  however,  is 
apt  to  follow. 

The  cushions  of  hypertrophied  mucous  membrane 
found  on  the  side  of  the  septum  near  its  posterior  edge 
cannot  well  be  reached  by  any  instrument  except  a  flat 
burner  under  the  guidance  of  the  mirror.  By  these 
means  they  can  be  easily  removed.  If,  however,  they 
are  seated  over  a  projecting  spur  of  bone,  they  can  be 
better  dealt  with  by  any  of  the  operations  applicable  to 
septum  deformities  (compare  1  123),  especially  the  spoke- 
shave. 

98.  A  relatively  rare,  but  not  unimportant,  complica- 
tion of  hypertrophic  rhinitis  is  edematous  occlusion  of 
the  nasal  passages.     This  occurrence,  which  the  writer 


1 86   SIMPLE    CHRONIC    RHINITIS HYPERTROPHIC    RHINITIS. 

has  not  found  described  in  literature,  has  been  observed 
a  few  times  as  a  sequel  to  an  acute  inflammatory  attack 
— usually  an  attack  of  influenza  in  patients  previously 
subject  to  hypertrophic  rhinitis.  Both  sides  of  the  nose 
were  occluded  for  weeks  by  edematous  infiltration  of  the 
entire  mucous  membrane.  The  lining  appeared  grayish 
pale  and  distinctly  soggy.  There  was  slight  turgescence 
of  the  cavernous  tissue.  The  reduction  of  the  turgescence 
by  cocain  restored  transiently  very  imperfect  nasal  per- 
meability. There  was  no  secretion  and  no  lesions  were 
found,  except  those  of  hypertrophic  rhinitis.  The  edema 
was  removed,  and  nasal  permeability  gradually  restored 
by  the  use  of  dilating  tampons  moistened  with  cocaiu 
solution.  As  soon  as  the  nasal  caliber  had  been  partially 
reestablished,  the  existing  hypertrophies  were  removed 
and  the  cure  thus  completed. 


CHAPTER  XIV. 
NASAL   POLYPI.     PAPILLOMATOUS   TUMORS. 

POLYPI  OF  THE  NASAL  PASSAGES. 

99.  Although  but  a  form  of  circumscribed  hypertrophy 
of  the  mucous  membrane,  nasal  polypi  present  pecu- 
liarities which  require  a  separate  description.  The  term 
polypus  is  applied  to  any  tumor  springing  from  a  free 
surface  by  a  constricted  pedicle.  Nasal  polypi  appear 
as  elongated  tumors,  usually  pendant  and  freely  movable. 
They  are  either  of  a  "  fleshy  "  appearance,  slightly  more 
reddish  than  the  normal  mucous  membrane,  and  of  solid 
consistency,  or  more  generally  they  are  soft  and  grayish 
translucent  by  reason  of  edema.  They  vary  in  size  from 
that  of  a  small  pea  to  the  largest  masses  which  can  be 
accommodated  by  a  nasal  passage.  They  are  more  often 
multiple  than  single,  more  often  bilateral  than  one-sided. 
Their  most  frequent  points  of  origin  are  the  free  border 
and  external  surface  of  the  middle  turbinal  and  the 
region  of  the  hiatus  semilunaris.  Smaller  ones  are  often 
hidden  underneath  the  middle  turbinal,  springing  from 
the  smaller  ledges  of  the  ethmoid  or  from  the  vicinity  of 
the  infundibulum.  In  rare  instances  a  polypus  from  the 
upper  part  of  the  maxillary  sinus  protrudes  through  the 
hiatus  into  the  nose.  Much  less  common  is  their  origin 
from  the  upper  ethmoid  structures.  Very  rarely  a  polypus 
is  attached  to  the  upper  part  of  the  septum.  Different, 
however,  from  the  ordinary  polypus  is  a  polypoid  bleed- 
ing tumor  occasionally  seen  on  the  septum — the  bleeding 
polypus  of  the  septum  (^  237).  Characteristic  polypi  do 
not  grow  from  the  inferior  turbinal,  although  sometimes 
a  cavernous  hypertrophy  may  assume  a  polypoid  shape 
(Figs.  54  and  55). 

187 


1 88  NASAL    POLYPI.       PAPILLOMATOUS    TUMORS. 

Polypi  are  rare  in  childhood,  very  common  only  after 
adolescence.  Ziickerkandl  found  polypi  in  over  lo  per 
cent,  of  unselected  subjects  in  the  dead-room. 

lOO.  The  symptoms  of  polypi  are  nasal  obstruction, 
more  or  less  proportionate  to  their  size.  Patients  often 
feel  the  moving  of  the  pendulous  masses  during  forcible 
breathing.     When  small  tumors  do  not  occlude  the  pas- 


FlG.  54. — External  wall  of  the  right  nasal  passage,  with  polypi  in  the  mid- 
dle and  the  superior  meatus  and  on  the  inferior  ethmoturbinal :  b.  Polypus 
originating  from  the  middle  turbinal ;  c,  polypus  in  the  inferior  ethmoidal 
fissure;  J,  dilated  infundibulum  harboring  a  polypus  (Zuckerkandl). 


sage  mechanically,  they  are  apt  to  cause  transient  ob- 
struction by  turgescence.  In  such  cases  there  is  usually 
much  nasal  irritability,  and  sneezing  fits,  transient  watery 
discharge,  and  distant  nervous  symptoms  are  quite  com- 
mon. The  most  frequent  distant  disturbance  caused  by 
polypi  is  asthma.  In  most  instances  polypi  are  associated 
with  purulent  rhinitis  or  suppuration  of  accessory  cavi- 


PATHOLOGY. 


189 


ties,  especially  the  anterior  ethmoid  cells.  There  are, 
however,  cases  in  which  there  is  no  discharge.  Bleeding 
is  not  caused  by  typical  polypi.  Occasionally  polypi  are 
partly  angiomatous  in  structure,  in  which  case  free 
hemorrhages  may  occur. 

loi.  Histologically,  polypi  present  the  structure  of 
mucous  membrane  with  inflammatory  round-cell  infiltra- 
tion (Fig.  56).     The  term  myxomatous  tumor,  formerly 


Fig.  55. — Lateral  wall  of  the  right  nasal  chamber,  with  two  large  polypi : 
i,  Infundibulum ;  c,  cyst  of  the  mucous  membrane ;  a,  accessory  maxillary 
orifice  (Zuckerkandl). 

applied  to  them,  is  hence  quite  incorrect,  as  they  are 
neither  tumors  in  a  pathologic  sense  nor  do  they  consist 
of  the  embryonal  connective  tissue  which  makes  up  a 
myxoma.  The  gelatinous  appearance  of  many  polypi  is 
due  to  edema.  This  edema  is  shown  by  the  enormous 
shrinkage  which  such  polypi  undergo  upon  drying. 
Under  the  micr-oscope  it  reveals  itself  by  infiltration  of 
the  tissue  with  serum,  which  coagulates  when  placed  in 


I9Q 


NASAL    POLYPI.       PAPILLOMATOUS    TUMORS. 


alcohol.  The  serous  infiltration  may  distend  the  meshes 
of  the  connective  tissue  to  such  an  extent  as  to  give 
some  polypi  a  cystic  appearance.  True  cysts,  however, 
lined  by  epithelium  occur  only  to  a  small  extent  in 
polypi.  The  growths  are  covered  by  the  normal  nasal 
epithelium.  Polypi  are  generally  not  very  vascular,  and 
possess  but  few  nerves.     The  number  of  glands  found  in 


Fig.  56. — Histologic  structure  of  a  nasal  polypus.  The  normal  stratified 
cylindric  epithelium  changes  toward  the  right  side  to  a  less  regular  stratified 
series  of  flattened  pavement  cells.  In  the  areolar  tissue  are  meshes  of  variable 
size,  filled  with  serum.  There  is  not  much  more  than  the  normal  amount  of 
cellular  (leukocytic)  infiltration  except  around  the  blood-vessels. 

them  varies  with  the  area  of  mucous  membrane  from 
which  they  spring. 

The  inflammatory  origin  of  these  growths  is  shown  by 
clinical  observation.  They  occur  mainly  in  connection 
with  suppurative  disease  of  the  nasal  passages  or  of  the 
accessory  cavities.  Well-ascertained  histories  often  teach 
that  polypi  are  started  by  prior  suppurative  disease,  which 
their  presence  then  serves  to  perpetuate.  The  finding 
of  the  polypus  should  always  direct  a  search  for  suppura- 
tion of  accessory  cavities,  especially  the  ethmoid  cells 
and  the  maxillary  sinus,  for  the  recurrence  of  extirpated 


TREATMENT.  I9I 

polypi  may  be  expected  sooner  or  later  if  the  primary 
suppuration  is  not  removed.  Yet  there  are  instances  in 
which  polypi  are  not  accompanied  by  any  form  of  in- 
tranasal or  adjoining  suppuration.  Another  condition 
which  is  often  found  clinically  as  a  predisposition  to 
polypus  formation  is  the  narrowing  of  one  nasal  passage 
from  septum  thickening  or  from  deviation.  In  such  cases, 
however,  polypi  are  usually  found  on  both  sides  of  the 
nose.  Polypi  cannot  be  considered  analogous  to  other 
hypertrophies  of  the  mucous  membrane  ;  for  the  over- 
growth constituting  the  polypus  is  not  diffuse,  but  is 
strictly  localized  in  a  small  area  which  continues  to  grow 
after  it  has  separated  itself  from  its  source  by  a  pedicle. 
The  constriction  of  the  pedicle  implies  that  the  growing 
•process  takes  place  only  in  the  body  of  the  polypus. 
There  must  hence  be  some  strictly  localized  stimulus 
causing  this  growth.  All  research  for  bacteria  has 
hitherto  been  negative. 

102.  A  polypus  incompletely  removed  undergoes  rapid 
regeneration,  but  complete  abscission  at  the  base  of  the 
pedicle  eradicates  it.  The  removal  of  a  polypus  often 
permits  small  ones  hitherto  concealed  by  it  to  grow  at  a 
more  rapid  rate,  but  when  the  polypi  have  been  com- 
pletely taken  away,  their  reappearance  need  not  be  exr 
pected  unless  some  suppurative  process  persists. 

103.  The  removal  of  a  polypus  is  easily  accomplished 
by  placing  the  snare  loop  around  its  pedicle  at  its  base- 
and  cutting  through.  Under  the  proper  use  of  cocain 
this  is  painless  and  generally  not  very  bloody.  If  the 
loop  cannot  be  pushed  up  to  the  very  base  of  the  pedicle, 
it  is  better  to  tear  off  the  polypus  after  tightening  the 
wire,  rather  than  to  cut  it  off  incompletely.  As  a  rule, 
some  of  the  mucous  membrane  from  which  it  springs  is 
thus  torn  away  with  it,  and  the  removal  is  complete. 
The  method  of  the  older  surgeons  to  seize  polypi 
with  forceps,  especially  without  the  use  of  the  mirror, 
can  only  be  condemned  as  inefficient  and  barbarous. 
When  the  polypus  is  not  accessible  to  the  wire  loop,  its 


192 


NASAL    POLYPI.       PAPILLOMATOUS    TUMORS. 


base  may  be  cut  away  with  a  sharp  curet.  The  hot 
snare  has  no  advantage  over  the  cold  wire.  The  use  of 
the  galvanocaustic  burner  involves  the  risk  of  obliter- 
ating the  orifices  of  accessory  cavities.  In  the  case  of 
narrow  nasal  passages  various  accessory  operations  may 
be  necessary  for  the  complete  eradication  of  polypi. 
When  they  are  multiple  on  or  underneath  the  middle 
turbinal,  it  is  often  best  to  amputate  the  front  end  of 


Fig.  57. — Papilloma  on  the  inferior  turbinal  (Zuckerkandl). 

that  process.  When  a  thickening  of  the  septum  inter- 
feres with  the  accessibility  of  the  growth,  some  form  of 
operation  on  the  septum  may  be  necessary  before  the 
nose  can  be  entirely  cleared.  After  the  removal  of 
polypi  all  hidden  foci  of  suppuration  must  be  sought  and 
cured  in  order  to  prevent  subsequent  growth. 

104.  Papillomatous  tumors  are  localized  overgrowths 
found,  as  a  rule,  mainly  on  the  inferior  turbinal.  In 
their  clinical  significance  they  are  analogous  to  polypi, 


PAPILLOMATOUS    TUMORS.  1 93 

differing  from  them  only  by  reason  of  the  different  area 
of  mucous  membrane  from  which  they  spring.  They  are 
much  less  common  than  polypi.  Their  structure  is  that 
of  the  mucous  membrane  covering  the  inferior  turbinal 
with  inflammatory  round-cell  infiltration.  These  growths 
occur  either  as  hard  or  as  soft  papillomata,  the  difference 
being  due  to  the  preponderance  of  fibrillary  connective 
tissue  in  the  former,  while  in  the  latter  the  abundant 
presence  of  round  cells  gives  them  almost  the  structure 
of  granulation  tissue.  The  name  of  papilloma  is  given 
to  these  growths  on  account  of  their  minutely  lobulated 
surface,  which  thus  resembles  the  papillary  structure  of 
the  skin.  In  appearance  they  may  be  aptly  compared  to  a 
raspberry,  which  they  also  resemble  in  color.  They  occur 
most  frequently  in  connection  with  chronic  purulent 
rhinitis,  and  their  presence  helps  to  perpetuate  the  sup- 
puration. They  can  be  easily  and  permanently  removed 
by  snaring  (Fig.  57). 

13 


CHAPTER   XV. 

NASAL  STENOSIS.— COLLAPSE  OF  THE  SIDES  OF 
THE  NOSE.— SYNECHIyC— OCCLUSION  OF  THE 
POSTERIOR  CHOAN>e. 

NASAL  STENOSIS. 

105.  While  the  width  of  the  nasal  passages  varies  in 
different  subjects  with  the  width  of  the  skull,  the  normal 
nose  offers  no  appreciable  resistance  to  the  current  of  air 
during  quiet  or  even  during  forcible  respiration.  Any 
narrowing  or  encroachment  upon  the  caliber  of  sufficient 
extent  to  impede  the  respiratory  current  is  termed  ste- 
nosis. In  default  of  more  accurate  physical  methods  of 
measurement  we  can  gauge  the  normal  or  diminished 
permeability  of  the  nasal  passage  by  auscultation.  When 
the  caliber  is  sufficient,  the  ingoing  or  outgoing  air  pro- 
duces no  sound,  even  while  breathing  forcibly.  Any 
interference,  however,  with  the  respiratory  capacity  of 
the  nose  causes  a  sound  varying  from  a  gentle  rustling 
noise  to  a  sharp  hiss.  The  more  forcible  the  breathing, 
the  more  distinct  is  the  sound.  Either  side  must  be 
tested  while  the  other  is  closed  by  the  thumb.  In  a  nose 
otherwise  not  diseased  stenosis  or  even  occlusion  of  one 
side  causes  no  annoyance  ordinarily  as  long  as  it  is  com- 
pensated by  full  width  of  the  other.  For  the  animal 
system  has  in  most  of  its  functions  an  excess  of  capacity, 
and  hence  some  physiologic  latitude.  But  when  the 
breathing  is  deepened  in  consequence  of  severe  exertion, 
the  nasal  passages  of  less  than  average  capacity  become 
insufficient,  and  the  individual  is  "short-winded."  If, 
however,  both  nostrils  are  narrowed, — a  condition  which 
occurs  only  in  consequence  of  disease  and  not  merely  as 
a  structural  anomaly, — the  subject  feels  the  difficulty  of 
breathing,  and  upon  the  least  exertion  is  forced  to  breathe 

194 


NASAL   STENOSIS.  1 95 

through  the  mouth.  Especially  is  this  the  case  in  the 
recumbent  position  (during  sleep),  when  the  increased 
venous  blood  pressure  in  the  low-lying  head  causes  ad- 
ditional nasal  obstruction  by  turgescence.  As  the  path  of 
the  air  through  the  mouth  is  cut  off  whenever  the  tongue 
arches  upward  so  as  to  touch  the  soft  palate,  which  move- 
ment often  takes  place  while  the  mouth  is  open,  the 
sleep  is  apt  to  be  interrupted  or  troubled  by  momentary 
dyspnea. 

Mouth-breathing,  furthermore,  subjects  the  throat  and 
lower  air-passages  to  abnormal  and  irritating  conditions. 
The  inspired  air  is  both  warmed  and  nearly  saturated 
with  moisture  in  passing  over  the  convoluted  surface  of 
the  normal  nasal  passage,  while  the  dust  it  contains  is 
almost  wholly  deposited  there.  None  of  these  conditions 
are  fulfilled  during  mouth-breathing.  The  cool,  rela- 
tively dry,  and  possibly  dusty  air  reaching  the  pharynx 
and  lower  air-passages  acts  as  an  irritant.  While  this 
irritation  by  itself  is  not  sufficient  to  cause  local  disease, 
it  aids  other  pathogenic  influences,  such  as  infection,  in 
overcoming  the  resistance  of  the  tissues. 

io6.  Nasal  stenosis  is  an  important  determining  condi- 
tion in  the  persistence  and  chronicity  of  all  forms  of  nasal 
inflammation.  It  favors  the  prolongation  of  a  coryza  in 
the  form  of  a  chronic  purulent  or  simple  rhinitis.  It 
predisposes  in  the  latter  case  to  the  occurrence  of  hyper- 
trophies, even  of  polypi.  It  hinders  the  free  drainage  in 
acute  suppuration  of  the  accessory  cavities,  and  thus  aids 
in  changing  these  into  chronic  affections.  Last,  but  not 
least,  all  forms  of  stenosis  exert  the  most  pernicious  in- 
fluence by  favoring  the  extension  of  inflammatory  disease 
through  the  Eustachian  tubes  into  the  ear.  Of  all  nasal 
diseases,  ozena  is  the  only  one  the  predisposition  to 
which  is  not  augmented  by  stenosis. 

When  a  one-sided  nasal  stenosis  has  become  compli- 
cated by  actual  nasal  disease,  stenotic  annoyance  is  felt  by 
the  patient  on  both  sides  on  account  of  the  variable 
turgescence  of  the  cavernous  tissue,  which  causes  tran- 


196 


NASAL   STENOSIS. 


sient  occlusion  of  one  or  the  other  side  alternately.  The 
patient  may  then  be  at  a  loss  to  state  which  seems  to  him 
the  narrower  side.  Nasal  stenosis  depends  principally  on 
the  deformities  of  the  septum,  which  will  be  considered 
in  the  next  chapter.  But  besides  the  septum  irregu- 
larities, other  structural  anomalies  may  require  con- 
sideration. Even  a  considerable  degree  of  deflection  of 
the  septum  may  lead  to  no  morbid  results  in  the  case  of 
a  naturally  wide  nasal  passage,  while  in  a  narrow  nose, 
a  relatively  slight  convexity  or  ridge  on  the  surface  of 
the  septum  may  cause  disastrous  consequences.  A  physio- 
logic septum  irregularity  which  originally  caused  no 
stenosis  may  do  so  after  hypertrophy  of  the  lining  of  the 
inferior  turbinal  has  furtlier  narrowed  the  nasal  passage. 
Hence,  even  when  the  septum  is  partly  at  fault,  opera- 
tions on  the  inferior  turbinal,  such  as  the  galvanocaustic 
destruction  of  cavernous  dilatation,  the  snaring  of  hyper- 
trophied  mucous  membrane,  or  complete  removal  of  the 

turbinal  process  in  case  of 
abnormal  projection  of  this 
ledge  or  diffuse  papilloma- 
tous degeneration  of  its  lin- 
ing are  sometimes  indicated 
if  the  mechanical  conditions 
are  not  favorable  for  opera- 
tions on  the  septum. 

107.  A  minor  condition, 
but  one  sometimes  deserving 
attention,  is  the  inspiratory 
collapse  of  the  sides  of  the 
nose  (alse  nasi).  Although 
itself  the  consequence  of 
some  intranasal  anomaly 
causing  stenosis,  it  intensi- 
fies the  latter.  With  ever}- 
inspiration  the  sides  of  the 
external  nose  sink  in,  thereby  slightly  narrowing  the 
vestibule.       It  occurs  in  connection  with  long-standing 


Fig.  58. — Schmidt's  dilator  for  col- 
lapse of  the  external  nares,  the  upper 
sketch  showing  it  in  position.  It  is 
made  in  various  sizes. 


NASAL   SYNECHIA.  1 97 

intranasal  stenotic  lesions,  and  only  in  subjects  whose 
alae  nasi  are  very  thin  and  flexible.  It  probably  de- 
pends on  insufficient  activity  of  the  dilating  muscular 
fibers.  The  want  of  breath  which  the  patient  feels 
is  relieved  at  once  by  keeping  the  nostrils  open — for 
instance,  by  the  speculum.  Temporary  relief  may  be 
obtained  by  the  use  of  the  wire  dilator  devised  by  M. 
Schmidt  and  constructed  by  Feldbausch.  Its  application 
is  shown  in  Fig.  58,  and  may  be  varied  slightly  by  bend- 
ing the  wire  frame.  It  is  made  in  three  sizes.  Occa- 
sionally its  temporary  use  is  followed  by  permanent  relief. 
By  other  surgeons  silver  tubes  have  been  used  for  the 
same  purpose,  but  these  are  often  not  so  well  tolerated  as 
a  wire  dilator  which  does  not  touch  the  septum. 

NASAL  SYNECHI/E. 

108.  Connecting  bridges  between  the  septum  and  the 
opposite  external  wall  are  formed  under  various  condi- 
tions. Their  most  frequent  cause  is  insufficient  care  after 
operations,  bloody  or  caustic,  in  narrow  passages,  when 
two  denuded  opposing  surfaces  are  not   prevented  from 


Fig.    59. — Luer   forceps   (especially   adapted   for   the   removal   of  intranasal 

synechise). 

growing  together.  A  lateral  crest  on  a  convex  septum 
may  touch  the  inferior  or  middle  turbinal  and  consolidate 
with  it  when  the  points  of  contact  are  involved  tran- 
siently in  an  acute  inflammation.  Broad  or  multiple  syne- 
chiae  are  very  often  due  to  nasal  syphilis.  In  some  cases 
synechiae   are  of  congenital   origin.      They  are   mostly 


198  NASAL   SYNECHIA. 

membranous,  but  occasionally  bony.  Sometimes  irrele- 
vant, they  may  in  other  instances  cause  stenosis  or  dam 
up  secretions.  Again,  they  may  be  the  starting-point  of 
nervous,  so-called  reflex,  disturbances.  They  are  easily 
removed  by  any  form  of  broad  rongeur  forceps  (Fig.  59), 
which  exsects  the  whole  bridge.  If  curvature  of  the 
septum  renders  them  less  accessible,  they  may  be  cut 
through  at  one  side  and  then  snared  off,  or  removed 
with  the  spoke  shave.  The  broad  synechiae  of  syph- 
ilis may,  however,  tax  the  surgeon's  ingenuity  to  the 
utmost. 

109.  Total  occlusion  of  one  nostril  at  its  anterior 
vestibular  entrance  has  been  observed  a  few  times  in 
consequence  of  destructive  processes  (syphilis,  lupus, 
small-pox,  and  rhinoscleroma). 

no.  Total  occlusion  of  the  posterior  choanae, 
while  not  a  frequent  occurrence,  is  on  record  in  more 
instances  than  anterior  closure  of  the  nose.  It  is  always 
congenital,  and  may  be  one-sided  or  bilateral.  The  one- 
sided closure  causes  scarcely  any  annoyance  so  long  as  the 
nose  is  otherwise  healthy;  only  the  sense  of  smell  is 
abolished  on  that  side.  Any  form  of  inflammation,  how- 
ever, leads  to  the  retention  of  secretion  and  subsequent 
annoyance.  The  closure  is  membranous  in  some  cases. 
In  others  it  consists  of  bony  plates  springing  from  the 
palatal  bone. 

The  diagnosis  of  choanal  closure  must  be  confirmed 
by  the  use  of  the  postrhinoscopic  mirror,  which  shows  a 
diaphragm  across  the  choanse.  If  this  is  membranous, 
it  can  be  easily  cut  through.  Should  it  not  be  possible 
to  exsect  it  sufficiently,  the  galvanocaustic  burner  may 
be  used.  Operations  on  bony  plates  closing  the  choanae 
are  more  difficult.  They  are  painful  and  bloody.  The 
posterior  wall  of  the  pharynx  must  be  guarded  by  the 
surgeon's  finger,  or,  still  better,  by  a  suitable  bent  plate 
introduced  through  the  mouth.  The  diaphragm  can  be 
pierced  by  a  stilet,  and  the  opening  enlarged  by  the  saw 
or  chisel.     It  is  much  better  to  make  a  large  opening  at 


TOTAL    OCCLUSION    OF    THE    POSTERIOR    CHOANiE.         I99 

once  than  to  attempt  to  enlarge  it  subsequently  by  any 
mechanical  means.  Sometimes  a  tube  must  be  worn  for 
weeks.  Among  the  recorded  operations,  some  of  them 
of  recent  date,  there  have  been  various  accidents,  such 
as  middle-ear  infection  and  even  an  occasional  death. 


CHAPTER   XVI. 

ANATOMY    OF    THE    SEPTUM.— DEVIATION    OR 

DEFLECTION  OF  THE  SEPTUM.— LATERAL 

CRESTS.— DEFORMITY  OF  SEPTUM 

BY  FRACTURE. 

III.  The  two  nasal  passages  are  separated  by  a 
median  wall  common  to  both — the  septum.  This  is 
made  up  in  front  and  below  of  the  quadrangular  carti- 
lage, in  its  upper  portion  of  the  vertical  plate  of  the 
ethmoid  bone,  while  its  inferior  posterior  part  is  the 
vomer.  The  extreme  anterior  tip  is  membranous  and 
consists  of  skin.  A  dense  perichondral  membrane  covers 
the  cartilage  underneath  the  mucous  membrane,  while 
the  bony  plates  have  a  periosteal  lining.  In  its  upper 
anterior  region  the  mucous  membrane  is  thickened  into 
a  tumefaction — the  tuberculum  of  the  septum — rich  in 
glands  and  veins.  Some  distance  above  the  floor  the 
mucous  membrane  forms  a  series  of  shallow  ridges  dur- 
ing development,  which  usually  dwindle  later  on,  but 
sometimes  enlarge  in  hypertrophic  rhinitis  (Fig.  60). 

During  its  early  fetal  formation  the  septum  is  a  single 
plate  of  cartilage  reaching  from  floor  to  roof.  About  the 
second  month  the  vomer  becomes  differentiated  in  the 
form  of  two  ossifying  parallel  plates,  joined  in  front, 
below,  and  behind,  but  including  between  them  the 
original  cartilaginous  layer.  Toward  birth  these  two 
bony  plates  coalesce,  with  disappearance  of  the  included 
cartilaginous  plate.  At  the  upper  border,  however,  the 
bony  plates  are  still  separated  by  a  groove  in  which  a 
strip  of  cartilage  persists.  By  this  time  the  vertical 
plate  of  the  ethmoid,  too,  has  ossified  from  above  down- 
ward, and  now  joins  the  upper  border  of  the  vomer, 
leaving  still  the  strip  of  cartilage  now  incased  by  bony 
200 


ANATOMY  OF  THE  SEPTUM. 


20 1 


walls.     This  condition  may  change  to  complete  ossifica- 
tion during  adult  life,  or  may  persist  indefinitely. 

112.  The  developed  vomer  represents  a  stout  bony 
lamella,  the  height  of  which  increases  from  before  back- 
ward, by  reason  of  the  slope  of  its  upper  or  anterior 
border.  Its  inferior  border  articulates  with  a  narrow 
ridge  at  the  median  junction  of  the  two  superior  max- 


FiG.  60. — Nasal  septum  after  detachment  of  its  mucous  lining :  Z,  Perpen- 
dicular plate  of  the  ethmoid;  V,  V,  vomer;  Q,  quadrangular  cartilage;  S 
nasal  spine  of  the  frontal  bone;  C,  nasal  crest  of  the  palate  bone  (Zuckerkandl). 


illary  and  the  two  palatal  bones,  reaching  thus  from  the 
front  to  the  rear  end  of  the  floor  of  the  nose.  The  slop- 
ing anterior  border  connects  partly  with  the  quadrangular 
cartilage,  and  back  of  it  with  the  vertical  plate  of  the 
ethmoid.  It  runs  up  to  the  rostrum  or  spine  on  the 
inferior  surface  of  the  sphenoid,  where  it  turns  to  form 
the  short  (superior)  border  articulating  with  the  rostrum. 
The  posterior  free  edge  of  the  vomer  slants  upward  and 
backward  and  is  concave. 

The  quadrangular  cartilage  articulating  in  front  and 
above  with  the  nasal  bones  forms  the  median  wall  of  the 


202  DEVIATION    OR    DEFLECTION    OF   THE   SEPTUM. 

external  nose.  The  triangular  cartilaginous  plates  of  the 
sides  of  the  nose  are  joined  to  it.  Its  inferior  anterior 
rounded  corner  is  framed  by  the  short,  thick,  membran- 
ous septum,  which  thus  completes  the  middle  wall  of  the 
external  nose.  The  inferior  border  of  this  cartilage  rests 
on  the  anterior  half  of  the  vomer.  At  this  contact  the 
edges  of  cartilage  and  bone  are  sometimes  square  ;  more 
often,  however,  the  cartilaginous  edge  is  bent  toward  one 
side  and  overlaps  the  bony  junction,  or  is  split  overriding 
the  bone  on  both  sides,  while  the  vomer  may  or  may  not 
have  its  groove  obliterated.  These  irregularities  of  the 
junction  are  the  starting-point  of  morbid  crests. 

The  vertical  plate  of  the  ethmoid  completes  the  gap 
between  the  roof  of  the  nose,  the  anterior  surface  of  the 
sphenoid  bone,  the  upper  border  of  the  vomer,  and  the 
cartilaginous  septum.  The  ossification  of  this  bony 
lamella  proceeds  from  above  downward  and  extends 
forward  to  a  variable  extent,  so  that  while  the  bridge 
of  the  nose  is  mostly  supported  by  this  bony  plate,  it 
rests  occasionally  only  on  the  cartilaginous  septum. 
The  ossification  is  completed  by  the  sixth  year,  at  the 
latest  about  the  ninth  year  of  life.  But,  as  before  de- 
scribed, a  strip  of  cartilage  usually  remains  after  this 
period,  for  a  variable  length  of  time,  incased  by  bony 
walls — viz.,  by  the  inferior  edge  of  the  vertical  ethmoid 
plate  and  the  trough  formed  by  the  upper  border  of  the 
vomer.  The  lateral  crests  so  often  found  in  the  nose  are 
due  to  hypertrophy  of  this  cartilaginous  remnant,  with 
secondary  bulging  of  the  sides  of  the  bony  trough. 

113.  The  normal  septum  is  not  always  an  ideal 
straight  wall.  Asymmetry  due  to  curvature  is  found  in 
more  than  one-half  of  all  skulls  of  the  white  races.  In 
iincivilized  tribes  septum  deviations  occur  only  to  the 
extent  of  about  25  per  cent.  The  deflection  pertains 
principally  to  the  cartilaginous  portion,  but  may  involve, 
to  a  variable  extent,  the  perpendicular  part  of  the  eth- 
moid plate.  The  deflected  septum  is  convex  and  bulging 
toward   one   side   and    correspondingly  concave   on   the 


CAUSES.  205 

other.  The  curvature  is  usually  more  marked  in  the 
vertical  than  in  the  horizontal  plane.  The  convexity 
may  be  scarcely  noticeable,  or  may,  on  the  other  hand, 
occlude  practically  the  one  nasal  passage.  Sometimes  a 
double  S-shaped  bend  is  met  with,  reducing  the  patency 
of  both  sides.  When  the  asymmetry  extends  to  the  front 
portion  of  the  septum,  the  external  nose  is  deflected  to 
one  side.  Occasionally,  but  not  often,  the  free  anterior 
end  of  the  cartilage  is  deflected  and  then  usually  thick- 
ened, so  as  to  occlude  partly  one  side  of  the  vestibule 
(Fig.  61).  The  architecture  of  an  asymmetric  septum 
is   very   often   complicated   by   the  existence  of  lateral 


Fig.  61. — Stenosis  of  the  right  nostril  by  thickening  and  deflection  of  the 
anterior  end  of  the  septal  cartilage.  The  membranous  septum  is  displaced  to 
the  left,  and  thereby  narrows  the  left  nostinl. 

crests  on  one  or  even  both  sides,  which  thicken  it  and 
augment  its  injurious  mechanical  influence. 

Regarding  the  causes  of  asymmetry  of  the  septum, 
many  unfounded  hypotheses  have  been  recorded.  But 
nothing  more  positive  can  be  stated  than  that  it  is  the 
result  of  a  disproportionate  growth  of  the  septum  as 
compared  with  that  of  the  rigid  bony  frame  within 
which  it  is  contained.  In  very  pronounced  cases  of 
curvature  it  is  sometimes  apparent  that  the  concavity 
of  the  septum  corresponds  to  the  smaller  maxillary  bone, 
which  has  not  attained  the  growth  of  its  mate,  giving 
the  entire  face  an  asymmetric  expression.  Pronounced 
asymmetry  is  rarely  observed  before  the  second  dentition. 
The  influence  of  traumatism,  so  often  quoted,  has  been 
much  overrated.     It  does  seem  in  some  instances  to  lead 


204 


LATERAL   CRESTS. 


to  an  exaggeration  of  a  preexisting  asymmetry,  but  it  is 
scarcely  probable  that  it  can  cause  a  deflection  without 
fracture  of  a  previous  straight  septum. 

114.  Less  frequent,  but  clinically  more  important, 
than  deviations  of  the  septum  are  the  lateral  crests,  also 
called  spurs  and  septal  ridges  or  spines.  They  occur  in 
about  every  third  skull  and  are  often  associated  with 
some  deflection.     The  lateral  crests  are  protuberances  on 


Fig.  62. — Frontal  section  through  the  nose,  showing  a  large  crest  on  the  left 
side  of  the  septum :  a,  a.  Septum  ;  b,  crest  (Zuckerkandl). 

the  side  of  the  septum  in  the  form  of  ledges  running 
backward  and  somewhat  upward.  They  begin  usually 
in  the  cartilaginous  portion,  but  sometimes  only  at  the 
bony  part,  and  may  or  may  not  extend  up  to  the  sphe- 
noid bone.  In  the  cartilaginous  portion  they  may  or 
may  not  be  double-sided.  In  the  bony  part  they  are,  as 
a  rule,  one-sided,  and  if  bilateral,  one  is  much  more 
prominent  than  the  other.     These  protuberances  may  be 


MODE   OF   ORIGIN.  205 

scarcely  prominent,  or  may  extend  laterally  far  enough 
to  touch  the  inferior  and  toward  the  rear  partly  the 
middle  turbinal  (Fig.  62).  The  rear  end  of  a  lateral 
crest  is  sometimes  covered  by  hypertrophic  and  turges- 
cent  mucous  membrane  in  the  form  of  the  gelatinous 
cushion  described  in  ^  94.  In  some  instances  sharp, 
cornice-like  projections,  the  lateral  crests  are  in  others 
diflfuse  flat  tumefactions.  Their  location  is  at  the  side  of 
the  anterior  sloping  border  of  the  vomer,  anywhere  from 
its  front  to  its  rear  end,  but  their  parallelism  with  this 
border  may  be  masked  by  their  variable  and  irregular 
height.  By  the  older  writers  the  spines  on  the  septum 
have  been  incorrectly  termed  ecchondroses  and  exostoses. 
These  terms  are  not  applicable,  as  they  refer  to  localized 
tumors  of  progressive  tendency,  and  of  a  structure  which 
the  lateral  crests  do  not  possess. 

The  mode  of  origin  of  lateral  crests  has  been  defi- 
nitely established  by  Zuckerkandl.  In  the  anterior  part 
of  the  septum  the  lateral  spurs  or  prominences  are  due  to 
the  lateral  overriding  of  the  edge  of  the  cartilaginous  plate 
over  the  edge  of  the  vomer,  with  more  or  less  hypertrophy 
of  the  displaced  cartilaginous  edge.  Further  back,  where 
the  vomer  and  the  vertical  plate  of  the  ethmoid  meet, 
the  lateral  crest  is  due  to  hypertrophy  of  the  strip  of 
cartilage,  which  persists  in  the  interior  of  this  articula- 
tion, incased  within  the  trough-like  border  of  the  vomer. 
This  hypertrophy  causes  bulging  of  the  bony  shell 
which  covers  it ;  hence  the  outer  wall,  at  least,  of  the 
lateral  crest  is  bony  ;  indeed,  sometimes  a  very  solid 
bony  plate.  Quite  often,  however,  the  hypertrophied 
cartilaginous  strip  itself  undergoes  later  on  ossification, 
in  which  case  the  lateral  crest  is  bony  throughout.  The 
cause  of  this  hypertrophy  has  not  been  fully  ascertained. 
Clinical  experience  points  to  an  inflammatory  origin, 
for  it  can  often  be  learned  that  in  noses  which  had  pre- 
viously presented  no  lateral  crest,  such  a  prominence  has 
gradually  developed  during  the  course  of  repeated  acute 
attacks  of  inflammation.     The   side   toward  which  the 


2o6 


DEFORMITY    OF   SEPTUM    BY    FRACTURE. 


bulging  of  the  enlarged  cartilage  occurs  is  partly  deter- 
mined by  the  previous  shape  of  the  septum.  When  this 
is  deflected,  the  crest  is,  as  a  rule,  on  the  convex  side. 
The  presence  of  the  crest  seems  to  increase  the  septum 
deformity,  and  in  such  cases  the  concavity  on  the  opposite 
side  of  the  septum  is  often  very  deep.  Within  the  carti- 
laginous portion  lateral  ridges  may  occur  on  both  sides, 
even  in  a  deflected  septum.  Traumatism  may  play  a 
slight  role  occasionally  in  exaggerating  the  growth  of 
lateral  crests,  but  careful  criticism  does  not  lead  to  the 
belief  that  it  is  a  common  or  essential  condition. 

115.  Deformity  of  the    septum   as  the  result  of  a  frac- 


V 

Fig.  63. — Old  fracture  of  nasal 
bones.  The  cartilaginous  septum  is 
bent  to  a  high  degree,  and  on  the 
left  side  touches  the  external  wall  in 
front  (Zuckerkandl). 


Fig.  64. — Old  fracture  of  the  nasal 
bones.  Dislocation  of  the  cartilag- 
inous septum  at  its  articulation  with 
the  vomer  (Zuckerkandl). 


ture  is  much  less  common  than  the  previously  described 
asymmetries.  According  to  Zuckerkandl' s  numerous 
dissections  and  experimental  tests,  fracture  of  the  septum 
can  occur  only  in  connection  with  fracture  and  disloca- 
tion of  the  nasal  bones.  As  this  accident,  unless 
promptly  treated,  always  leads  to  lasting  deformity  of 


CLINICAL    SIGNIFICANCE    OF   SEPTUM    DEFORMITIES.       20/ 


the  bridge  of  the  nose,  the  presence  or  absence  of  the 
latter  can  guide  the  diagnosis.  Fractures  of  the  septum 
pertain  essentially  to  the  cartilaginous  plate  ;  much  less 
so  to  the  vertical  plate  of  the  ethmoid.  The  vomer 
seems  to  be  protected  by  its  strength  and  its  deep  situa- 
tion. The  fraccures  are  usually  horizontal  ;  much  less 
often,  vertical.  The  fractured  ends  overlap  and  often 
become  thickened.  Within  the  cartilaginous  portion 
they  are  reunited  by  connective  tissue.  In  the  bony 
portion  only  a  thin  callus  is  formed.  The  deformity 
resulting  from  fracture  is  a  sharp,  angular  bend,  usually 
with  very  great  thickening  of  the  mucous  membrane  on 
the  concave  side.  A  traumatism  sufficient  to  break  the 
nasal  bones  may  also  dislocate  the  cartilaginous  plate 
over  the  vomer  edge,  causing 
thus  an  excessive  thickening  in 
front,  near  the  floor  of  the  nose 
(Figs.  6s,  64,  65). 

116.  Another  tumefaction  on 
the  septum,  while  not  uncom- 
mon, but  of  relatively  little  clin- 
ical importance,  is  the  hyper- 
trophy of  the  cushion  of  mucous 
membrane  in  the  anterior  upper 
part,  known  as  tiibercMliini  of  the 
septum.  This  may  be  thickened 
by  hypertrophy  of  the  mucous 
membrane,  with  more  or  less  over- 
development of  the  venous  plex- 
us. Even  when  very  thick  it 
does  not  interfere  with  the  cur- 
rent of  air,  but  it  may  interfere 
with  the  drainage  of  secretions 
to  a  sufficient  extent  to  justify 
its  reduction  by  the  galvanocautery  or  its  abscission  with 
a  knife, 

117.  Clinical    Significance     of    Septum    Deformities. — The 
disturbances    due   to   irregularities   of    the    septum   de- 


FiG.  65. — Fracture  of  the 
cartilaginous  septum  with  ob- 
struction of  the  anterior  ends 
of  the  nasal  passages. 


208       CLINICAL   SIGNIFICANCE    OF    SEPTUM    DEFORMITIES. 

pend  upon  their  mechanical  influence.  Deviation  of 
the  septum  is  in  no  sense  of  the  word  a  disease,  merely 
an  unfavorable  structural  anomaly.  Lateral  crests, 
while  really  a  morbid  overgrowth,  are  likewise  of  sig- 
nificance only  if  they  interfere  with  the  permeability 
of  the  nasal  passage.  The  most  important  effect  of 
septum  deformities  is  the  stenosis  which  they, may  pro- 
duce, and  this  depends  upon  their  prominence,  as  well 
as  upon  the  natural  width  of  the  nasal  passage.  If  no 
stenosis  sound  is  heard  during  examination,  it  must  not 
be  concluded  that  the  septum  prominence  is  harmless, 
for  it  may  lead  to  partial  occlusion  whenever  the  venous 
plexus  is  turgescent,  and  certainly  will  do  so  during  in- 
flammatory attacks.  A  one-sided  stenosis,  if  compen- 
sated by  full  width  of  the  other  passage,  does  not  neces- 
sarily lead  to  annoyance  nor  to  disastrous  results,  so  long 
as  the  nasal  mucous  membrane  is  healthy  ;  it  merely 
makes  the  patient  short-winded  on  exertion.  But  it  is 
an  important  condition  favoring  the  persistence  of  any 
inflammation.  Hence  repeated  or  severe  attacks  of 
coryza  are  very  apt  to  lead  to  hypertrophic  rhinitis  under 
these  circumstances.  Clinical  observation  shows  also  the 
importance  of  septum  irregularities  in  the  maintenance 
of  suppurative  rhinitis  or  suppuration  of  the  accessory 
cavities,  the  occurrence  of  polypi,  and  in  the  extension 
of  nasal  disease  to  the  pharynx,  lar^'ux,  and  bronchial 
tubes.  The  most  striking  observations  are  those  which 
show  the  influence  of  one-sided  stenosis  together  with 
inflammatory  nasal  disease  in  the  production  of  ear  dis- 
ease. This  may  be  either  acute  or  it  may  be  a  chronic 
adhesive  process  extending  through  the  Eustachian  tube 
in  the  middle  ear.  In  the  case  of  one-sided  nasal  steno- 
sis a  one-sided  ear  affection  occurs  almost  invariably  on 
the  narrow  side,  ver\'  rarely  on  the  other  side.  In 
bilateral  ear  disease  the  side  most  severely  involved 
corresponds  in  the  overwhelming  majority  to  the  nar- 
rower side  of  the  nose.     Quite  often,  too,  ear  affections 


DIAGNOSIS    OF    SEPTUM    DEFORMITIES.  2O9 

persist  in  spite  of  all  treatment  of  the  ear  until  the  nasal 
stenosis  has  been  successfully  relieved  by  operation. 

The  pernicious  influence  of  nasal  stenosis  has  been 
ascribed  to  rarefaction  of  the  air  behind  the  narrowed 
part  of  the  passage  during  every  inspiration.  It  has 
been  assumed  that  in  consequence  of  this  increased  nega- 
tive pressure,  a  permanent  congestion  of  the  mucous 
membrane  occurs.  This  hypothetic,  but  plausible,  view 
does  not  fully  explain  all  the  injurious  effects  resulting 
from  stenosis.  It  is  very  noticeable  that  in  deflection 
of  the  septum  the  inferior  turbinal  shows,  as  a  rule,  pro- 
nounced hypertrophy  of  the  mucous  membrane  on  the 
concave,  roomy  side  of  the  nose. 

A  septum  irregularity  which  does  not  sensibly  interfere 
with  the  passage  of  air  may  interfere  with  the  escape  of 
morbid  secretions  to  such  an  extent  as  to  favor  the  per- 
sistence of  suppurative  processes.  Hence,  the  operative 
removal  of  spurs  and  ledges  often  permits  the  cure  of 
previously  unyielding  nasal  suppuration. 

Lateral  crests  may  also  be  the  source  of  nervous  dis- 
turbances in  irritable  noses.  In  the  majority  of  cases  of 
vasomotor  irritability  lateral  prominences  are  found  on 
the  septum.  It  is  especially  those  with  a  sharp  edge 
which  seem  to  irritate  most.  Even  greater  importance 
can  be  attributed  to  lateral  crests  which  extend  far 
enough  laterally  to  touch  the  inferior  or  middle  turbinal, 
be  it  permanently  or  only  during  periods  of  turgescence. 
Some  of  the  most  satisfactory  cures  of  nasal  irritability 
can  be  obtained  by  the  removal  of  such  ledges,  even 
when  they  do  not  cause  the  auscultation  sound  of  stenosis. 
A  crest  which  extends  far  enough  to  touch  a  turbinal 
process  may  become  united  to  it  by  a  bridge  of  mucous 
membrane,  causing  a  nasal  synechia.  This  junction 
seems  to  augment  sometimes  the  pernicious  influence  of 
the  crest.  On  the  other  hand,  very  prominent  crests 
may  cause  localized  atrophy  of  the  turbinal  process 
where  they  come  in  contact  with  it. 

118.  The  diagnosis  of  septum  irregularities  is  self-evi- 

14 


2IC  SEPTUM    DEFORMITIES. 

dent  from  their  description.  When  the  anterior  region 
of  the  nose  is  narrow,  it  is  necessary  to  explore  the  deeper 
part  thoroughly  with  the  probe  under  good  illumination, 
in  order  to  get  a  clear  picture  of  the  extent  of  the  septum 
irregularity.  The  indications  for  operative  interference 
are  very  plain,  and  the  results  eminently  satisfactory  in 
all  high  degrees  of  septum  irregularities.  But  in  minor 
degrees  of  septum  asymmetry  and  thickening  the  me- 
chanical chances  for  success  are  not  so  favorable.  Hence 
in  such  cases  it  must  be  carefully  considered  whether  the 
disturbances  observed  are  principally  due  to  the  encroach- 
ment of  the  septum  deformity  upon  the  nasal  caliber,  or 
whether  they  are  due  to  any  coexisting  hypertrophies  on 
the  external  nasal  wall,  as  the  latter  are  more  easily 
removed  by  operation.  Small  and  insufficient  operations 
on  the  septum  are,  as  a  rule,  to  be  deprecated  as  useless. 
An  incompletely  removed  lateral  crest  is  very  likely  to 
continue  its  growth;  for  if  we  remove  only  the  bony 
shell  covering  the  hypertrophied  cartilage  nucleus,  the 
latter  will  grow  again  later  on. 

Many  surgeons,  including  the  writer,  have  been  tempted 
to  obtain  straightening  of  a  deflected  septum  or  atrophy  of 
a  lateral  crest  by  some  form  of  continuously  applied  pres- 
sure. But  hitherto  all  these  attempts  have  proved  failures. 
Pressure  by  tampons,  tubes,  or  metallic  springs  leads  to 
ulceration  of  the  septum  if  kept  up,  and  if  discontinued, 
its  effect  is  soon  lost.  Successful  operations  upon  septum 
deformities  have  been  extensively  practised  only  within 
the  past  fifteen  years.  The  operative  attempts  of  the 
older  surgeons,  tried  merely  in  extreme  cases,  were  mostly 
failures.  In  the  present  treatise  only  those  operations 
generally  recognized  can  be  considered. 

119.  The  simplest  and  most  satisfactory  correction  of 
a  deviated  septum  is  the  operation  devised  by  M.  J.  Asch, 
which  can  be  done  in  a  few  minutes.  Its  object  is  to 
fracture  the  cartilaginous  septum  and  to  let  it  heal  in  a 
straight  position.  General  narcosis  is  usually  employed, 
with  the  head  hanging  over  the  edge  of  the  table  on  ac- 


OPERATIONS    UPON    THE   SEPTUM. 


211 


count  of  the  sharp  bleeding.  A  tolerant  patient,  how- 
ever, can  bear  it  under  cocain,  especially  when  injected 
into  the  mucous  membrane.  The  nose  should  first  be 
explored  for  adhesions  between  septum  and  external  wall, 
and  if  found,  they  should  be  cut  with  cutting  forceps  or 
a  concave  gouge.  The  straight  Asch  forceps  are  then 
introduced  horizontally,  with  the  narrow  blunt  blade  on 


Fig.  66. — Asch's  instruments  :    A,  Straight   scissors ;    B,  angular  scissors ;   C, 
compressing  forceps. 

the  narrow  side  (Fig.  66).  The  cartilage  is  cut  through, 
exactly  over  the  apex  of  its  convexity.  The  scissors  are 
then  inserted  as  nearly  vertical  as  possible,  so  as  to  make 
a  crucial  incision,  splitting  the  cartilage  into  four  flaps. 
When  the  straight  scissors  cannot  be  well  inserted  for 
the  vertical  cut,  the  more  cumbersome  bent  scissors  may 
be  employed.  The  finger  is  now  put  into  the  narrower 
side,  and  the  fragments  are  crowded  over  to  the  other. 


212  CORRECTION    OF   SEPTUM    DEFORMITIES. 

The  cartilaginous  flaps  should  be  fractured  at  their  base. 
The  Asch  compressor  is  then  inserted,  and  the  fracture 
completed  with  the  intention  to  render  the  septum  as 
nearly  straight  as  possible.  Asch  does  not  advise  frac- 
turing the  bone,  even  if  the  latter  be  deflected.  The 
sharp  hemorrhage  can  be  controlled  quickly  by  an  iced 
spray  or  temporary  tampons.  As  soon  as  this  is  checked, 
the  Asch  or  (improved)  Mayer  tubes  are  inserted.  They 
are  made  of  rubber,  perforated,  and  somewhat  curved 
(Fig.  67),  oval  in  cross-section,  and  in  six  sizes.  They 
bear  sterilizing  by  boiling.  The  largest  one  possible  is 
inserted  on  the  formerly  convex  side  until  concealed 
within  the  vestibule.  Its  object  is  to  keep  the  septum 
straight  while  healing.  The  smaller  one  is  put  into  the 
other  side  for  the  first  twelve  hours,  in  order  to  guard 


Fig.  67. — Mayer's  hollow  nasal  splints. 

against  bleeding,  and  is  then  omitted  permanently.  The 
tube  on  the  formerly  convex  side  is  removed  once  daily 
for  cleansing,  and  the  nasal  secretion  is  cleared  away  by 
a  spray.  The  removal  and  reinsertion  should  be  painless. 
The  patient  can  learn  to  do  it  himself  after  a  few  days. 
The  healing  is  completed  in  three  and  one-half  to  four 
weeks,  when  the  tube  can  be  left  out.  The  fractured 
fragments  overlap  on  the  formerly  concave  side,  and 
their  edges  sometimes  thicken  later  on.  Occasionally 
this  requires  shaving  off  with  the  scalpel,  or  slight 
touching  with  a  burner. 

The  operation  gives  ideal  results  in  the  case  of  a  curved, 
bent,  but  not  thickened  septum,  with  plenty  of  room  on 
the  concave  side.  When  a  moderate-sized  lateral  crest 
complicates  the  septum  deflection,  it   may  be   removed 


OPERATIONS  UPON  THE  SEPTUM.  21 3 

{%  122)  just  before  the  septum  is  fractured.  With  very 
diffuse  thickening,  however,  or  stenosis  on  the  concave 
side  the  Asch  operation  is  not  applicable. 

120.  For  extreme  cases  of  septum  curvature,  even  if 
complicated  by  lateral  crests,  a  more  radical  operation 
has  been  devised  by  Krieg  and  cultivated  especially  by 
Boenninghaus.  It  is  the  resection  of  the  deflected  cartil- 
age. On  account  of  its  tediousness  the  German  surgeons 
usually  operate  under  cocain  and  without  narcosis.  With- 
out speculum  two  incisions  are  made  at  the  beginning  of 
the  curvature  on  the  convex  side,  one  parallel  to  the  floor, 
the  other  parallel  to  the  bridge  of  the  nose.  The  incisions 
go  through  the  mucous  membrane  only  and  are  not  quite 
I  cm.  long,  on  account  of  the  free  hemorrhage  following, 
which  jnust  now  be  stopped.  Suprarenal  solution  aids 
more  than  mere  tamponing.  The  triangular  flap-mem- 
brane thus  outlined  is  then  pushed  back  with  a  large 
blunt  periosteum  scraper.  Hereupon  the  incisions  can 
be  extended  gradually  as  far  as  necessary,  until  the  entire 
curved  part  of  the  septum  is  exposed.  The  detached 
mucous  membrane  is  temporarily  pushed  out  of  place 
by  crowding  it  upward  and  back.  In  the  next  place  the 
incision  is  extended  through  the  cartilage  itself,  with 
care  not  to  wound  the  mucous  lining  on  the  concave  side. 
This  may  be  guarded  against  by  putting  the  finger  into 
the  concave  side.  This  step  can  also  be  facilitated  by 
lifting  up  the  mucous  membrane  on  the  concave  side  by 
means  of  submucous  injection  of  fluid  (with  cocain).  Per- 
forations are  not  always  avoidable.  The  incision  through 
the  cartilage  is  extended  by  means  of  scissors,  always 
with  the  same  care  to  spare  the  mucous  membrane  on 
the  other  side.  The  liberated  cartilaginous  triangle  now 
shows  the  tension  under  which  it  was  restrained,  and 
bends  further  toward  the  external  wall.  It  is  seized  with 
stout  rongeur  forceps  and  broken  off  piecemeal.  This 
gradual  removal  of  the  deflected  plate  must  extend  to 
the  bone  if  necessary.  At  the  same  time  lateral  crests 
are  taken  away  in  the  same  manner,  so  as  to  clear  the 


214  CORRECTION   OF  SEPTUM    DEFORMITIES. 

nose  entirely.  There  is  very  little  hemorrhage  during 
the  work  upon  the  cartilage.  The  bleeding  comes  mainly 
from  the  cuts  in  the  mucous  membrane.  After  a  sufficient 
extent  of  the  deflected  septum  has  been  removed,  the 
operation  is  finished.  The  wall  between  the  two  nasal 
cavities  now  consists  only  of  the  intact  mucous  membrane 
on  the  concave  side.  Krieg  and  Boenninghaus  do  not 
attempt  to  preserve  the  lining  on  the  convex  side,  as  they 
claim  that  it  rolls  up  and  cannot  be  stitched  in  place. 
(But  by  much  care  it  can  be  preserved,  at  least  partially, 
and  the  time  of  healing  shortened  by  the  temporary  use 
of  carefully  inserted  tampons  which  retain  it  in  place.) 
The  great  advantage  of  this  operation  is  the  fact  that 
practically  no  after-treatment  is  necessary.  The  wound 
heals  in  seven  to  eight  weeks,  but  requires  no  special 
care.  The  result  is  a  perfectly  straight  septum.  No 
sinking  in  of  the  bridge  of  the  nose  has  been  observed  or 
needs  to  be  feared. 

Partial  resection  of  the  cartilage  has  been  practised  by 
the  writer  in  deflection  occurring  at  the  extreme  front  end 
of  the  septum,  especially  when  the  free  border  adjoining 
the  membranous  septum  is  bent  and  at  the  same  time 
thickened.  In  cases  of  this  kind  the  obstruction  is  com- 
paratively within  the  vestibule  (see  Fig.  6i).  No  typical 
operation  is  suitable  for  all  cases,  but  by  cutting  upward 
or  downward  with  a  knife  the  cartilaginous  projection  is 
abscised  flush  with  the  normal  plane  of  the  septum.  It 
is  sometimes  possible  to  save  part  of  the  mucous  mem- 
brane by  detaching  a  flap,  as  in  the  Krieg  operation. 

121.  Lateral  crests  of  the  septum  can  be  removed 
easily  by  the  saw,  according  to  the  method  of  Bosworth. 
A  thin  saw,  mounted  on  a  shank  bent  at  an  obtuse  angle, 
is  introduced  in  the  plane  of  the  septum,  and  with  a 
steady  to-and-fro  movement  the  entire  ledge  is  sawed  off". 
Usually  the  teeth  of  the  saw  are  underneath,  but  some- 
times it  is  more  convenient  to  use  it  reversed  and  saw  up- 
ward (Fig.  68).  It  is  sometimes  difficult  to  detach  com- 
pletely the  sawed-off"  crest,  in  which  case  its  rear  attach- 


OPERATIONS  UPON  THE  SEPTUM. 


215 


ment  is  separated  either  by  use  of  the  snare  or  by  scissors. 
The  use  of  suprarenal  solution  facilitates  the  work  by 
making  it  almost  bloodless.  It  aids,  besides,  the  action 
of  cocain,  so  that  a  pledget  wet  with  20  per  cent,  solution 
will  give  perfect  painlessness  after  five  minutes'  applica- 
tion. Subsequent  hemorrhage  may  render  temporary 
tamponing   desirable.      The   wound   heals   smoothly   in 


Fig.  68. — Nasal  saw. 

from  one  to  two  and  one-half  weeks,  according  to  its 
size;  more  slowly,  however,  if  it  be  ragged  or  irregular. 
The  results  are  perfectly  satisfactory  if  a  sufficiently  large 
piece  has  been  removed.  When  the  sides  of  the  crest 
slope  very  gradually,  it  is  difficult  to  use  the  saw  prop- 
erly. This  is  also  the  case  when  the  ledge  extends  up  to 
the  sphenoid  surface. 

Some  surgeons  like  M.   Black  claim  to  facilitate  the 
operation   by  using  a   saw  driven    mechanically  by  the 


Fig.  69. — Author's  nasal  chisel  (two-thirds  size). 

rapid  rotation  of  the  hand-piece  of  a  dental  motor. 
Others  prefer  the  use  of  a  chisel  and  mallet,  which  is  a 
matter  of  individual  preference  or  skill.  There  are  cases 
where  there  is  so  much  slope  on  the  upper  and  lower 
sides  of  the  crest,  with  a  relatively  square  front  surface, 
that  the  chisel  is  more  applicable.  The  writer  has 
devised  a  hollow  chisel  of  elliptic  cross-section,  of  which 


2l6  CORRECTION    OF    SEPTUM    DEFORMITIES. 

only  one-half  has  a  cutting-edge  (Fig.  69).  This  instru- 
ment, pressing  itself  against  the  external  wall,  cannot 
slip  like  a  plane  chisel,  and  is  bound  to  gouge  out  the 
projecting  ledge.  It  is  of  service  in  the  case  of  very- 
broad  diflfuse  tumefaction,  especially  when  situated  on 
the  convex  side  of  a  nearly  plane  septum.  It  is,  how- 
ever, apt  to  cause  perforation,  which,  in  the  writer's 
experience,  has  not  proved  a  serious  objection. 

1^2.  In  the  case  of  crests  difficult  to  saw  by  reason  of 
their  sloping  surface  a  very  serviceable  instrument  is  the 
trephine  run  by  a  motor  with  a  dental  handpiece.  As  it 
is  difficult  to  hold  this  instrument  steady,  the  writer  uses 
it  under  the  guidance  of  a  sheath  into  which  it  fits  closely 
(Fig.    70).     This   cylindric   sheath   has  one  half  of  its 


Fig.  70. — Nasal  trephine,  with  author's  guarding  sheath  (two-thirds  size). 

periphery  removed,  so  as  to  hug  the  ledge  upon  which 
the  trephine  is  to  act.  When  the  crest  consists  of 
such  hard  bone  that  the  trephine  gets  caught,  a  smaller 
one  is  first  used  within  the  same  guard  to  perforate 
the  crest  longitudinally  and  weaken  it  thereby,  where- 
upon the  larger  trephine  easily  cuts  it  away.  Work 
with  the  trephine  is  much  quicker  than  with  the  saw.  It 
can  be  used,  too,  to  good  advantage  in  order  to  reach  up 
to  the  rear  end  of  crests  extending  up  to  the  sphenoid 
surface.  As  the  entire  width  of  the  trephine  is*only  8 
mm. ,  it  can  merely  cut  a  groove  with  a  radius  of  about 
4  mm.  In  the  case  of  broad  ledges  the  guard  is  with- 
drawn after  the  first  cut  and  reapplied  slightly  turned, 
so  as  to  inclose  now  the  balance  of  the  tumefaction, 
which   a   second    action   of  the  trephine   thereupon  re- 


OPERATIONS  UPON  THE  SEPTUM.  21/ 

moves  satisfactorily.  The  only  objection  to  the  tre- 
phine is  that  the  wound  made  by  it  is  concave,  and  its 
healing  is  more  likely  to  be  delayed  by  crust- formation 
than  the  plane  wound  made  by  the  saw. 

Lateral  ledges  and  spurs  limited  to  the  cartilaginous 
portion  can  be  cut  off  smoothly  with  a  sharp  knife. 

When  the  contour  of  a  crest  has  so  gradual  a  slope 
— for  instance,  on  the  convexity  of  a  curved  septum — 
that  it  is  difficult  to  apply  the  knife  properly,  the  spoke- 
shave  which  cuts  backward  can  often  be  substituted 
advantageously  (Fig.  71).  The  instrument  is  pushed  in 
until  its  cutting-edge  surrounds  the  spur  from  the  rear. 


fT''-^ 


sm 


Fig.  71. — The  spokeshave  in  two  sizes.  The  third  knife,  in  the  shape  of  an 
incomplete  ring,  is  used  when  a  total  stenosis  hinders  the  introduction  of  the 
other  forms.     Universal  handle  for  nasal  instruments  (one-half  size). 

On  pulling  it  out  with  the  necessary  strength  while  keep- 
ing it  pressed  against  the  septum  even  hard  bony  crests 
can  be  abscised  thoroughly  in  one  sweep  without  danger 
of  accidental  injury.  The  same  instrument  may  be  used 
to  smoothen  uneven  wounds  made  by  any  other  mode  of 
operation. 

i«3.  The  wounds  made  by  these  various  modes  of 
operation  heal  kindly,  as  a  rule.  The  hemorrhage  may 
persist  for  hours,  but  is  not  serious.  An  aseptic  healing 
cannot  be  guaranteed,  but  is  usually  obtained,  especially 
as  -long  as  the  passage  is  evenly  packed  with  iodoform 
gauze.  Where  the  patient  had  previously  not  been  able 
to  breathe  through  that  side  of  the  nose,  this  packing  is 


2l8  CORRECTION    OF    SEPTUM    DEFORMITIES. 

not  complained  of.  But  most  patients  without  previous 
complete  stenosis  prefer  the  slower  healing  with  unob- 
structed passage  to  the  advantages  gained  by  a  gauze 
tampon.  The  best  but  still  not  absolutely  reliable  sub- 
stitute for  iodoform  gauze  the  writer  has  found  in  glutol, 
which  adheres  quite  well  to  the  wound.  Other  powders, 
like  iodoform  or  any  of  its  substitutes,  do  not  stay  in 
place  at  all,  but  are  washed  away  by  the  watery  secretion 
of  the  wound.  With  open  treatment  surgical  wounds  of 
the  septum  do  not  usually  suppurate,  and  practically 
never  ulcerate.  The  healing,  especially  if  the  wound  is 
not  even,  is  apt  to  be  delayed,  however,  by  the  formation 
of  crusts.  As  long  as  no  infection  has  occurred  these 
wounds  are  painless.  When  they  become  inflamed,  dull 
pain  is  sometimes  referred  to  the  teeth,  or  described  as  a 
diffuse  headache.  Slight  fever  may  be  observed  in  such 
instances  for  a  few  days,  but  the  wound,  as  a  rule,  does 
not  show  the  infection  by  any  altered  appearance  except 
slight  swelling  of  its  edges.  Occasionally  infection  leads 
to  tonsillitis  on  the  same  side,  which  may  later  on  pass 
to  the  other  tonsil. 

124.  As  a  substitute  for  bloody  operations  electrolysis 
of  cartilaginous  ledges  has  been  recommended  by  vari- 
ous writers.  Two  needles  connected  with  insulated 
conducting  cords  are  inserted  into  the  septum  promi- 
nence, and  an  electric  current  up  to  the  strength  of  about 
25  milliamperes  is  gradually  turned  on.  This  current, 
requiring  a  battery  of  20  to  30  cells,  is  continued  for  five 
to  ten  minutes,  and  then  is  again  gradually  turned  off. 
Any  sudden  increase  or  diminution  in  the  strength  of  the 
current  causes  a  very  painful  shock.  As  the  negative 
pole  is  the  active  one,  the  positive  pole  may  be  used  in 
the  form  of  a  large  external  sponge  instead  of  a  needle  in 
the  septum.  This  procedure  has  no  influence  upon  bony 
crests,  but  it  does  cause  a  gradual  shrinkage  of  cartil- 
aginous prominences.  If  the  effect  is  insufiicient,  it  may 
be  used  repeatedly  at  intervals  of  about  two  weeks.  It 
is,  however,  painful,  and  the  inflammatory  reaction  fol- 


OPERATIONS  UPON  THE  SEPTUM.         '  2ig 

lowing  it  always  lasts  several  weeks,  and  sometimes  leads 
to  localized  necrosis  of  the  cartilage  with  perforation. 
Moreover,  it  is  not  always  efficient.  Its  indication  is 
hence  to  be  restricted  to  the  case  of  flat,  diffuse  tumefac- 
tions in  very  narrow  noses  in  which  surgical  instruments 
cannot  be  used  satisfactorily.  It  is  certainly  not  a  desirable 
substitute  for  any  other  feasible  operation. 

The  galvanocaustic  burner  can  be  recommended  as  a 
more  satisfactory  measure  for  the  reduction  of  smaller 
prominences  -on  the  cartilaginous  septum.  It  is  not  a 
substitute  for  a  clean  cutting  operation  when  the  latter  is 
mechanically  feasible.  But  narrow  crests  which  encroach 
sensibly  upon  the  caliber  because  they  happen  to  be 
situated  on  the  convex  side  of  a  moderately  bent  septum 
can  be  completely  removed  by  a  number  of  multiple 
punctures  or  a  few  linear  incisions  with  a  knife-shaped 
white-hot  burner.  The  wounds  heal  in  two  to  three 
weeks  without  unpleasant  reaction,  and  the  cicatrization 
causes  enough  shrinkage  to  clear  the  passage. 


CHAPTER  XVII. 
EPISTAXIS— HYDRORRHOEA  NASALIS. 

EPISTAXIS— NOSEBLEED. 

I25«  Bleeding  from  the  nose  may  depend  on  various 
intranasal  lesions  or  different  systemic  disturbances.  As 
a  matter  of  convenient  reference  it  is  well  to  summarize 
these  different  conditions  under  one  head.  The  loss  of 
blood  from  the  nose  may  var>'  from  a  mere  trifle  to  a 
flow  alarming  by  its  persistence.  Yet  there  are  probably 
no  immediate  fatal  results  on  record,  as  the  hemorrhage 
usually  stops  in  the  end  by  reason  of  fainting.  The 
frequent  recurrence  of  bleeding  may,  however,  cause 
serious  anemia  and  lessen  the  resisting  power  to  other 
diseases. 

The  most  common  lesion  causing  nosebleed  is  ulcera- 
tion of  the  septum  in  the  anterior  inferior  region  imme- 
diately behind  the  pyriform  aperture,  the  ulceration 
being  the  intermediate  stage  between  anterior  dry  rhini- 
tis and  perforating  ulcer  (1  75).  If  the  health  is  other- 
wise good,  the  bleeding  from  this  lesion  is  generally  not 
copious.  When  the  bleeding  spot  can  be  seen,  the  hem- 
orrhage can  be  checked  by  cauterization  with  a  bead  of 
nitrate  of  silver  or  a  cotton  pledget  containing  (melted) 
trichloracetic  acid.  The  galvanocautery  presents  no  ad- 
vantage over  chemical  cauterization.  Either  measure  may 
fail  for  the  time  being  and  packing  may  prove  necessary. 

A  comparatively  rare  lesion,  but  one  which  bleeds 
freely,  is  the  "bleeding  polypus  of  the  septum  "  (1  237). 
Its  site  is  above  the  usual  location  of  the  septum  ulcer. 
It  appears  as  a  small,  red  polypoid  tumor,  bleeding  freely 
on  touch.  If  well  accessible,  it  should  be  snared  radi- 
cally, otherwise  its  base  should  be  completely  cut  throiigh 
with  the  galvanocaustic  burner. 
220 


EPISTAXIS— NOSEBLEED.  221 

Very  copious  bleeding  can  be  caused  by  intranasal 
tumors  which  are  partly  made  up  of  cavernous  tissue. 
This  applies  to  benign  polypi,  suspicious  adenomatous 
tumors,  as  well  as  to  malignant  cancers.  Excessive  hem- 
orrhage may  also  be  due  to  an  unmixed  angiomatous 
growth.  Postnasal  fibromata  are  likewise  very  prone  to 
bleed  freely,  more,  however,  into  the  pharynx  than 
throuofh  the  nose.  Slig:ht  nosebleed  occurs  to  some 
extent  in  children  with  enlarged  pharyngeal  tonsil. 

Transient  bleeding  may  be  caused  by  a  blow,  usually 
without  lasting  lesion.  Any  nasal  operation  may  be 
followed  by  secondary  bleeding  within  the  first  few 
days.  Sudden  diminution  of  air  pressure  in  ascending 
high  mountains  starts  bleeding  from  the  nose  in  many 
persons. 

Nosebleed  with  or  without  visible  septal  lesion  may 
depend  on  various  systemic  conditions.  After  typhoid 
fever,  in  the  course  of  grave  anemia,  but  especially  in 
any  form  of  pernicious  anemia,  as  well  as  in  leukocythe- 
mia,  it  may  prove  difficult  to  manage.  In  scurvy  and 
hemophilia  it  is  more  likely  trivial  if  spontaneous,  but 
if  traumatic  in  a  bleeder,  it  gives  cause  for  anxiety. 
Nosebleed  is  an  early  symptom  in  typhoid  fever,  less  so 
in  measles  and  scarlatina,  in  which  latter  case  it  is  said 
to  be  indicative  of  severe  infection. 

In  middle  or  advanced  life  epistaxis  may  indicate 
arteriosclerosis  and  thus  prove  a  forerunner  of  cerebral 
softening.  The  nosebleed  referable  to  the  climacteric 
period  in  women  is  probably  also  dependent  on  some 
change  in  the  blood-vessels.  Hemorrhage  from  the  nose, 
vicarious  for  suppressed  menstruation,  is  occasionally 
observed,  but  its  frequency  has  been  exaggerated. 

If  epistaxis  occurs  with  symptoms  of  nasal  inflamma- 
tion, fibrinous  rhinitis  or  nasal  diphtheria  should  be 
thought  of. 

126.  In  any  ordinary  case  of  nosebleed  the  patient 
should  be  instructed  to  sit  up,  or,  better  still,  stand  up,  in 
order  to  lower  the  blood  pressure  and  to  plug  the  nostrils 


222  EPISTAXIS — HTDROKRHCEA    NASALIS. 

with  cotton.  Wiping  and  other  useless  meddling  merely 
protracts  the  bleeding.  The  popular  practice  of  placing 
anything  cold  (for  instance,  a  key)  on  the  nape  of  the  neck 
probably  causes  reflex  action  of  the  vasomotor  nerves  and 
is  not  without  some  utility.  Severe  bleeding  requires 
surgical  plugging  with  gauze  (or  cotton  in  case  of  emer- 
gency). Slight  bleeding  is  easily  controlled  by  the  use 
of  suprarenal  solution  on  cotton.  But  there  has  not  been 
enough  experience  with  this  agent  to  state  definitely 
whether  it  can  be  relied  upon  in  grave  cases  and  whether 
it  checks  hemorrhage  permanently.  Pledgets  wet  with 
antipyrin  solution  (lo  per  cent.)  often  act  quicker  than 
mere  mechanical  plugging,  especially  if  the  pledgets  are 
dusted  with  tannin  powder.  The  latter  alone,  however, 
is  not  of  much  use.  In  dangerous  cases  Monsell's  solu- 
tion of  iron  is  certain  in  its  action,  but  very  disagreeable 
by  reason  of  the  firm  clot  which  it  produces.  Whenever 
the  blood  flows  into  the  pharynx  in  spite  of  nasal  plug- 
ging, a  tampon  must  be  placed  in  the  nasopharynx  by 
means  of  Belloc's  sound  (or  by  aid  of  a  rubber  drainage- 
tube  pushed  through  the  nose)  (1  29).  In  all  instances 
the  lesion  causing  the  bleeding  should  be  looked  for  as 
soon  as  practicable  and  treated. 

127.  Nasal  hydrorrhea  (or  rhinorrhea),  a  discharge 
of  a  clear  watery  fluid  from  the  nose,  is  a  symptom  of 
variable  significance.  It  is  most  frequently  seen  in  con- 
nection with  sneezing  fits  in  nasal  irritability.  This  may 
depend  in  some  instances  on  abnormal  turgescence  of 
cavernous  tissue  in  neurotic  subjects  (vasomotor  coryza), 
while  in  others  it  is  due  to  the  presence  of  polypi.  In 
cases  of  this  nature  the  hydrorrhea  occurs  as  a  spell 
of  short  duration.  In  less  common  instances  the  watery 
discharge  lasts  longer  and  is  very  profuse.  Within 
less  than  an  hour  many  handkerchiefs  may  be  satu- 
rated. Much  less  common  is  a  continuous  discharge 
lasting  day  and  night.  Its  cause  can  usually  not  be 
determined.  A  few  times  it  has  been  seen  in  connection 
with  disease  of  the  fifth  nerve,  either  neuralgia  or  paraly- 


HYDRORRHCEA   NASALIS.  223 

sis.  In  some  instances  the  internal  use  of  atropin  has 
proved  of  service.  In  other  instances  the  fluid  dropping 
from  the  nose  is  cerebrospinal  fluid.  This  diagnosis  is 
favored  by  finding  in  it  chemically  a  substance  reducing 
Fehling's  (copper  sulphate)  solution  like  sugar.  An 
escape  of  cerebrospinal  fluid  may  occur  as  the  result  of 
a  fracture  of  the  base  of  the  skull.  A  few  fatal  cases 
have  been  reported  in  which  a  continuous  flow  of  clear 
fluid  from  the  nose  accompanied  atrophy  of  the  optic 
nerves  with  pronounced  contraction  of  the  visual  fields 
and  with  the  presence  of  other  cerebral  symptoms  (head- 
ache and  vertigo).  The  autopsies  showed  a  perforation 
of  the  roof  of  the  sphenoid  sinus  due  to  tumors  of  the 
hypophysis  cerebri  or  other  basal  tumors  or  hydro- 
cephalus. 


CHAPTER   XVIII. 

ANATOMY   OF  THE   TONSILS.      ACUTE    INFLAMMA- 
TION OF  THE  PHARYNX  AND  OF  THE  TONSILS 

(ANGINA). 

128.  Anatomy  of  the  Adenoid  Tissue  and  Tonsils. 

— The  shape  and  topographic  anatomy  of  the  pharynx 
have  been  described  in  Chap.  I.,  1  6,  and  Chap.  III., 
1  24,  the  structure  of  its  lining  membrane  in  Chap.  I., 
1  7.  For  a  study  of  the  diseases  of  this  region  some 
further  details  concerning  the  adenoid  tissue  are  neces- 
sary. The  entire  mucous  membrane  of  the  pharynx  is 
normally  infiltrated  with  lymphoid  cells,  but  a  special 
localized  development  of  lymphoid  tissue  surrounds  the 
anterior  entrances  into  the  pharynx  in  the  form  of  a 
"lymphatic  ring,"  as  termed  by  Waldeyer.  This  is 
constituted  by  the  two  faucial  tonsils,  the  bridge  of  ade- 
noid tissue  stretched  across  the  base  of  the  tongue  (the 
lingual  tonsil),  and  the  pharyngeal  tonsil  at  the  roof  of 
the  pharynx.  Under  morbid  circumstances  lymphatic 
tissue  may  also  develop  in  visible  masses  in  the  form  of 
follicles  on  the  posterior  wall  of  the  pharynx,  and  espe- 
cially in  the  form  of  the  (hypertrophied)  lateral  cords  of 
the  pharynx. 

The  faucial  tonsils  form  a  slightly  prominent  cushion 
in  the  space  bounded  by  the  anterior  and  posterior  pillars. 
The  pillars  themselves  are  projecting  folds  of  mucous 
membrane,  practically  the  downward  prolongation  of  the 
free  border  of  the  soft  palate  extending  down  to  the 
tongue.  Above  each  tonsil  and  underneath  the  superior 
junction  of  the  two  pillars  is  a  recess,  sometimes  a  deep 
pocket — the  supratonsillar  sinus.  The  tonsil  itself  is  a 
thickening  of  the  mucous  membrane  due  to  the  develop- 

224 


ANATOMV    OF   THE    TONSILS. 


225 


ment  of  lymph-follicles  within  a  delicate  capsule  (Fig. 
72).  The  tonsil  is  marked  by  about  one  dozen  pits  lined 
by  mucous  membrane  (and  pavement  epithelium) — the 
lacunae  or  crypts.  Any  distinct  prominence  of  the  ton- 
sillar tissue  must  be  considered  a  morbid  enlargement. 

Across  the  base  of  the  tongue  there  extends  a  bridge  of 
lymphoid  tissue — the  lingual  tonsil.  Besides  the  diffuse 
development  of  lymph-follicles,  this  area  presents  a  trans- 


FlG.  72. — Histologic  structure  of  the  hypertrophied  faucial  tonsil.  Soft 
(cellular)  form  of  childhood.  The  normal  pavement  epithelium  is  penetrated 
by  leukocytes  to  such  an  extent  normally  that  the  appearance  of  stratification  is 
partly  effaced.  The  epithelium  sends  offshoots  into  the  underlying  adenoid 
tissue.  The  lymphatic  structure  does  not  differ  essentially  from  a  normal  speci- 
men. The  blood-vessels  are  larger  and  more  numerous  than  in  the  normal 
tonsil. 

verse  row  of  larger  lymphatic  nodules,  each  from  i  to  4 
mm.  wide,  containing  a  central  crypt. 

The  pharyngeal  tonsil  consists  of  a  cushion  of  mucous 
membrane  thickened  by  the  development  of  follicles  so  as 
to  project  in  the  form  of  shallow  sagittal  ridges,  six  or 
seven  in  number,  which  coalesce  in  front  and  behind. 
It  begins  at  the  roof  of  the  pharynx,  about  5  mm.  be- 
hind the  upper  rim  of  the  choanse,  and  has  a  length  of 
about  2  cm.  Transversely  it  does  not  extend  into  the 
fossae  of  Rosenmiiller.  The  recess  between  the  central 
ridges  is  sometimes  developed  into  a  deeper  pit,  the 
pharyngeal  bursa.     This  is  not  always  present.     Like  in 

15 


226  ANATOMY    OF    THE    TONSILS. 

the  faucial  tonsil,  the  mucous  membrane  dips  into  shal- 
low pockets  termed  crypts.  The  epithelium  covering  the 
pharyngeal  tonsil  is  ciliated  cylindric,  while  that  over 
the  faucial  and  lingual  tonsils  is  stratified  pavement,  the 
same  as  throughout  the  lower  pharynx. 

The  adenoid  tissue  of  all  the  tonsils  consists  of  minute 
lymph-nodules  surrounded  by  a  fibrillar  stroma  and  filled 
with  lymph-cells. 

From  all  the  tonsillar  structures  there  occurs  normally 
an  outpour  of  leukocytes,  which  can  be  seen  in  microscopic 
sections  between  the  cells  and  on  the  surface  of  the  epi- 
thelium, making  it,  indeed,  difficult  to  define  the  outline 
of  the  epithelial  layer.  The  object  of  this  egress  of 
wandering  corpuscles  is  not  known.  In  fact,  it  cannot 
be  said  that  we  know  anything  definite  about  the  physi- 
ology of  the  tonsils.  They  are  capable  of  very  active 
absorption  of  minute  solid  particles,  like  pigment  gran- 
ules. 

ACUTE  TONSILLITIS.i 

139.  Diffuse  or  Catarrhal  Tonsillitis — Follicular 
or  I^acunar  Tonsillitis. — Acute  tonsillitis  is  a  com- 
mon, typical  infectious  disease  of  self-limited  duration. 
Two  varieties  are  described — viz.,  the  diffuse  catarrhal 
or  erythematous  tonsillitis,  in  which  the  tonsil  appears 
diffusely  reddened,  and  the  follicular  or  lacunar  form,  in 
which  small  white  exudates  protrude  from  the  orifices  of 
the  crypts.  There  seems  to  be  no  essential  difference 
between  these  two  varieties,  excepting  the  more  active 
participation  of  the  lining  of  the  crypts  in  the  follicular 
form.  Diffuse  tonsillitis  without  lacunar  involvement 
is  much  less  common  than  the  other  variety.  Tonsillitis 
begins  with  chilliness,  fever,  headache,  and  diffuse  pains 
through  the  muscles  and  general  malaise  and  lassitude. 
The  temperature  may  reach  104°  F.  in  children,  102°  to 
103°  in  adults.  The  systemic  disturbances  cease  promptly 
within  two  to  three  days  in  most  instances.    They  are  pro- 

1  Tonsillitis  and  all  forms  of  pharyngeal  inflammation  are  often  termed 
angina  by  continental  authors. 


ACUTE   TONSILLITIS.  22/ 

longed  if  the  disease  begins  in  one  tonsil  and  then  spreads 
to  the  other,  while  more  commonly  both  tonsils  suffer 
alike  from  the  start.  There  are  some  forms  of  tonsillitis 
in  which  the  systemic  disturbance  may  last  four  or  five 
days,  on  account  of  a  bacterial  infection  different  from 
that  of  the  ordinary  form  of  the  disease.  The  lymph- 
glands  of  the  neck  are  usually  enlarged,  sometimes  tender. 
Occasionally  splenic  tumefaction  is  demonstrable.  From 
the  start  the  throat  is  sore,  especially  on  swallowing,  but 
the  pain  is  only  moderate.  On  inspection  the  tonsils  are 
found  enlarged  and  red.  The  degree  of  enlargement  de- 
pends somewhat  on  the  previous  size  of  the  tonsil,  but  even 
tonsils  of  normal  size  may  swell  enormously  and  some- 
times recede  again  perfectly  on  recovery.  In  the  so-called 
diffuse  form  there  is  uniform  redness  of  the  surface.  The 
redness  extends  always  beyond  the  pillars,  in  the  form  of 
collateral  hyperemia.  In  the  follicular  variety  the  white 
spots  protruding  from  the  crypts  give  a  characteristic 
appearance.  The  surface  redness  is  not  always  very  pro- 
nounced in  this  form.  The  small ^white  plugs  consist  of 
detached  epithelium  interspersed  with  bacteria,  especially 
cocci.  Sometimes  the  follicular  exudate  extends  in  the 
form  of  separate  bits  of  false  membrane  suggesting  the 
possibility  of  diphtheria..  There  are  even  instances  where 
the  entire  tonsil  is  covered  by  a  distinct  coherent  mem- 
brane, in  which  the  diagnosis  of  diphtheria  can  be  ex- 
cluded only  by  the  absence  of  the  diphtheria  bacillus. 
The  clinical  course  of  these  (less  common)  forms  of  mem- 
branous tonsillitis,  although  a  little  more  severe  than  that 
of  the  ordinary  variety,  is  still  that  of  a  tonsillitis,  and 
not  that  of  true  diphtheria.  The  final  criterion  is  the 
absence  of  postdiphtheritic  sequels  and  the  inability  to 
transmit  diphtheria  to  others. 

The  local  appearances  in  tonsillitis  persist  a  few  days 
after  the  systemic  disturbances  are  over.  When  the  upper 
respiratory  passages  had  previously  been  healthy,  com- 
plete recovery  takes  place  inside  of  a  week  from  the 
beginning.     In  the  case  of  a  previously  diseased  nose  or 


228  ACUTE   TONSILLITIS. 

throat  the  local  recovery  is  somewhat  delayed,  or  tonsil- 
litis may  even  persist  for  a  time  in  a  subacute  form.  The 
membranous  variety  lasts  a  few  days  longer  than  the 
simple  form. 

130.  In  rare  instances  follicular  tonsillitis  is  limited  to 
a  small  part  of  one  or  both  tonsils.  In  such  cases  the 
systemic  disturbance  is  nearly  as  pronounced  as  in  the 
ordinary  form,  but  the  local  lesion  may  scarcely  be  felt 
by  the  patient  and  can  easily  be  overlooked. 

131.  Complications. — While  tonsillitis  follows  usually  an 
uncomplicated  course,  complications  and  sequels  are  not 
rare.  The  most  frequent  danger  is  to  the  ear,  in  the  form 
of  acute  suppurative  otitis.  In  a  certain  proportion  of 
cases  not  fully  estimated  numerically  tonsillitis  is  fol- 
lowed by  acute  articular  rheumatism,  especially  in  adults. 
It  seems  as  if  the  cause  of  rheumatism,  not  yet  identified, 
entered  through  the  tonsils  in  such  instances.  ]\Iuch  less 
frequently  there  are  observed  apparently  pyemic  acci- 
dents, metastatic  phlegmons,  localized  inflammations, 
and  even  endocarditis.  The  swollen  cervical  glands 
occasionally,  but  rarely,  suppurate. 

132.  Etiology. — Tonsillitis  is  most  common  in  child- 
hood, not  rare  in  middle  life,  but  not  often  seen  after  this 
period.  In  some  subjects  it  is  frequently  recurrent,  some- 
times repeatedly  in  one  season.  These  recurrences  dimin- 
ish after  the  growth  of  the  body  is  completed.  Chronic 
inflammation  of  the  tonsils,  especially  when  in  connec- 
tion with  nasal  suppuration,  predisposes  to  acute  attacks 
of  tonsillitis.  Occasionally  the  disease  attacks  appar- 
ently normal  and  not  enlarged  tonsils.  Tonsillitis  spreads 
so  often  throughout  the  household  that  the  contagious- 
ness, of  some  forms  at  least,  cannot  be  doubted.  While 
the  disease  is  commonly  attributed  to  a  cold,  "such  an 
etiology  can  be  but  rarely  demonstrated."  The  influence 
of  exposure  is,  however,  suggested  by  the  preponder- 
ance of  tonsillitis  during  periods  of  inclement  weather. 
Typical  tonsillitis  is  sometimes  seen  after  nasal  opera- 
tions followed  by  slight  local  infection.     Its  origin  from 


DIAGNOSIS.  229 

the  wound  is  shown  by  the  limitation  to  the  tonsil  of 
the  corresponding  side,  although  the  second  tonsil  may 
become  involved  subsequently. 

The  disease  has  been  attributed  to  infection  by  the 
streptococcus,  which  is  nearly  always  demonstrable  on 
the  surface  and  in  the  exudate.  Still,  as  this  is  a  fre- 
quent inhabitant  of  the  normal  mouth,  its  presence  on 
the  surface  does  not  establish  its  role  absolutely.  Of 
more  importance  is  its  demonstration  in  the  interior  of 
(amputated)  acutely  inflamed  tonsils  (Frankel),  and  in 
the  fluid  drawn  from  the  interior  of  the  tonsil  (Lemoine). 
French  observers  have  described  other  forms  of  tonsil- 
litis dependent  upon  the  presence  of  staphylococci, 
pneumococci,  the  pneumobacillus  of  Friedlander,  and 
the  coli  bacillus,  but  without  specifying  the  clinical 
peculiarities  of  these  forms.  It  must  be  emphasized 
that  the  diphtheria  bacillus  can  give  rise  to  a  simple 
tonsillitis  in  rare  instances  which  does  not  differ  in 
appearance  from  the  non-diphtheritic  form. 

133.  While  inspection  establishes  at  once  the  patho- 
logic diagnosis  of  tonsillitis,  the  etiologic  significance  of 
an  inflamed  tonsil  may  deserve  serious  attention  for  the 
purpose  of  a  differential  diagnosis.  In  the  first  place 
diphtheria  must  be  thought  of  A  non-membranous 
tonsillitis  is  rarely  of  diphtheritic  origin,  but  still  such  a 
suspicion  is  justified  especially  when  exposure  to  diph- 
theria has  occurred.  The  systemic  disturbances  of 
diphtheritic  tonsillitis  without  membrane-formation  are 
usually  not  so  pronounced  as  in  the  ordinary  non-diph- 
theritic form.  But  a  positive  diagnosis  can  be  made  only 
by  finding  the  diphtheria  bacillus  microscopically  or  in 
culture.  A  membranous  tonsillitis,  on  the  other  hand, 
may  or  may  not  be  of  diphtheritic  origin.  The  more 
acute  the  onset,  the  less  likely  is  the  diphtheritic  nature, 
but  here,  too,  the  decision  is  given  only  b}'^  the  presence 
of  the  specific  bacillus.  Scarlet  fever  may  begin  as  a 
typical  tonsillitis  before  the  rash  comes  out,  or  may  con- 
tinue as  such  even  without  rash.     It  should  be  suspected 


230  ACUTE   TONSILLITIS, 

when  there  is  a  diffuse  deep  redness  of  the  soft  palate  and 
uvula,  and  when  vomiting  occurs.  Syphilis,  too,  pro- 
duces occasionally  a  typical  picture  of  follicular  tonsilli- 
tis, but  the  clinical  course  is  different  in  this  case.  The 
disease  is  not  of  sudden  onset,  does  not  produce  the 
intense  systemic  involvement,  and  lasts  many  days  un- 
changed, but  accompanied  by  a  low  fever. 

134.  Under  the  head  of  treatment  text-books  present 
a  formidable  and  suspiciously  long  array  of  drugs  for 
both  internal  and  local  use  in  acute  tonsillitis,  and  each 
author  lauds  his  own  method.  An  unbiased  discoverer 
can  draw  one  inference  only  from  the  comparison  of 
different  text-books.  We  possess  at  present  no  method 
of  treatment  which  can  shorten  the  typical  course  of  any 
infectious  disease,  except  the  so-called  specific  medication 
— viz.,  the  artificial  employment  in  an  intensified  form  of 
those  means  by  which  the  organism  rids  itself  of  the 
disease  during  natural  recov^ery.  Such,  for  instance,  is 
the  treatment  of  diphtheria  by  antitoxic  serum.  There 
is  neither  any  logical  reason  nor  any  definite  experience 
to  warrant  the  belief  that  we  can  abort  an  attack  of 
tonsillitis.  All  claims  to  this  effect  are  based  either  on 
the  want  of  recognition  of  the  self-limJtation  of  the 
disease,  or  on  the  confusion  of  acute  tonsillitis  with  sub- 
acute aggravations  of  chronic  pharyngeal  trouble.  We 
can  minister  only  to  the  comfort  of  the  patient,  and  by 
combating  the  liability  to  complications,  obtain  the 
shortest  possible  course  of  tonsillitis.  The  febrile  dis- 
comfort may  be  lessened  by  the  use  of  alcoholic  drinks. 
Headache  and  bone-ache  can  be  allayed  by  antipyrin. 
Sleep  may  be  enforced  by  chloral  or  even  morphin  if  the 
patient's  condition  demands  it.  Any  gargle  which  tends 
to  check  secondary  decomposition  in  the  mouth  is  agree- 
able and  apparently  useful,  even  though  it  does  not  reach 
the  tonsillar  surface  to  any  extent.  The  writer  has  been 
pleased  with  the  clinical  effects  of  a  combination  which 
certainly  lessens  the  odor  of  the  breath  and  adds  to  the 
patient's  local  comfort.     It  is  : 


ACUTE    INFLAMMATION    OF   THE    LINGUAL   TONSIL.        23 1 

Thymol i 

01.  gaultheriae 0.5 

01.  cassise 0.5 

Chloroform 5 

Alcohol 25 

To  be  mixed  with  one  quart  of  water  (or  two  teaspoons  to  the  glass  of  water) 
for  gargling. 

It  must  be  used  at  very  short  intervals  in  order  to  obtain 
any  lasting  effect.  Chlorate  of  potassium  in  saturated 
solution  has  enjoyed  much  popularity  as  a  gargle,  but  on 
doubtful  grounds.  The  dangerously  poisonous  nature  of 
the  drug,  which  has  caused  many  deaths,  should  curtail 
its  use,  especially  in  children.  There  is  not  much  more 
to  be  gained  by  using  any  so-called  antiseptic  sprays. 
The  liability  to  persistence  of  tonsillitis  in  a  subacute 
form  after  the  acute  symptoms  have  subsided  can  be 
effectually  checked  by  various  topical  applications,  such 
as  nitrate  of  silver  (lo  to  15  per  cent.)  or  tincture  of  iron. 
The  writer  has  seen  the  best  effects,  however,  from  the 
use  of  lyoffler's  solution  (compare  1  25). 

Much  can  be  done  to  guard  against  the  habitual  re- 
currence of  tonsillitis.  Our  action  must  depend  upon 
the  previous  history  of  the  patient.  Enlarged  tonsils 
liable  to  become  inflamed  should  be  abscised.  Smaller, 
irregularly  shaped,  but  chronically  inflamed  tonsils  which 
cannot  be  removed  satisfactorily  may  be  rendered  harm- 
less by  cauterization  with  the  galvanic  burner.  A  pointed 
burner  bent  like  a  hook  should  be  introduced  into  every 
visible  crypt,  whereby  the  crypts  become  obliterated 
(compare  ^  151)- 

135.  Acute  inflammation  of  the  lingual  tonsil  is  a 
rare  occurrence  which  manifests  itself  by  the  same  sys- 
temic disturbance  as  ordinary  tonsillitis.  The  pain  is 
rather  more  acute,  especially  during  swallowing,  and  is 
referred  to  the  base  of  the  tongue.  On  searching  with 
the  mirror  the  lingual  tonsil  is  found  swollen,  red,  and 
often  marked  with  specks  of  lacunar  exudation.  What- 
ever has  been  said  of  the  course  of  treatment  of  faucial 
tonsillitis  applies  equally  to  the  present  form  of  disease. 


232  ACUTE   TONSILLITIS   AND    PHARYNGITIS. 

136.  Acute  inflammation  of  the  pharyngeal  tonsil 

is  a  subject  scarcely  mentioned  in  literature  until  recently, 
though  it  forms  part  of  most  cases  of  severe  coryza. 
The  only  additional  symptoms  to  which  it  gives  rise, 
besides  those  directly  due  to  the  nasal  inflammation,  are 
purulent  discharge  in  the  throat  and  very  slight  soreness 
on  swallowing.  Collateral  hyperemia  may  extend  down 
into  the  oral  part  of  the  pharynx.  Postrhinoscopic  in- 
spection shows  acute  inflammation  at  the  roof  of  the 
phar^mx. 

Acute  tonsillitis  of  the  pharyngeal  tonsil  may  also 
occur  in  rare  instances  as  an  independent  affection.  The 
writer  has  seen  about  half  a  dozen  instances,  mostly  in 
children.  It  begins  like  tonsillitis,  but  lasts  usually 
somewhat  longer,  up  to  six  or  nine  days.  In  all  instances 
there  had  previously  been  unimpeded  nasal  pemieability 
until  within  some  hours  after  the  fever  began.  The  nose 
was  more  or  less  blocked,  especially  during  sleep,  and 
•  the  voice  acquired  the  nasal  twang  characteristic  of  en- 
largement of  the  phar\mgeal  tonsil.  There  was,  how- 
ever, no  coryza  with  it,  but  moderate  mucopurulent 
secretion  in  the  throat.  Pain  was  not  mentioned.  The 
mirror  inspection,  often  unsatisfactory  in  children,  showed 
redness  in  the  upper  part  of  the  pharj-nx,  while  the 
finger  could  detect  a  swelling  and  some  tenderness  of  the 
pharyngeal  tonsil.  In  all  instances  the  phar}'ngeal  ton- 
sil regained  its  normal  size,  and,  after  recovery,  perfect 
nasal  respiration  became  reestablished.  In  some  of  the 
later  instances  the  writer  made  applications  of  Lofiler's 
solution  during  the  latter  part  of  the  disease,  apparently 
with  beneficial  results.  The  intense  irritation  due  to 
Lofiler's  solution  did  not  last  long.  No  complications 
were  observed. 

ACUTE  PHARYNGITIS. 

137.  Acute  diffiise  inflammation  of  the  entire  pharyn- 
geal lining  is  not  so  common  a  disease  as  tonsillitis.  It 
occurs  mostly  in  children.     It  begins  like  tonsillitis  and 


ACUTE    PHARYNGITIS.  233 

has  about  the  same  duration,  sometimes  lasting  a  few- 
days  longer.  There  is  rather  more  pain  on  swallowing 
than  in  tonsillitis.  There  is,  besides,  some  mucopuru- 
lent secretion  coming  from  the  roof  of  the  pharynx.  The 
entire  pharyngeal  lining  appears  diffusely  red.  Occa- 
sionally a  few  white  lacunar  specks  are  seen  in  the  center 
of  follicles  on  the  posterior  wall.  Such  follicles,  how- 
ever, had  existed  before  the  disease.  In  many  instances 
pharyngitis  is  combined  with  tonsillitis.  Pure  pharyn- 
gitis has  not  the  liability  to  recurrence  characteristic  of 
inflammation  of  the  tonsil.  Its  course,  causes,  complica- 
tions, and  treatment  are  the  same  as  in  tonsillitis. 

138.  A  rare  occurrence  which  the  patient  is  apt  to 
consider  as  an  acute  inflammation  in  the  throat  is  edema 
of  the  uvula.  It  begins  suddenly,  with  some  soreness, 
usually  without  recognizable  cause,  and  gives  rise  to  a 
feeling  of  foreign  body,  which  the  patient  is  tempted 
to  swallow.  The  discomfort  may  increase  to  intense 
anguish.  On  inspection  the  uvula  is  seen  to  be  swol- 
len, sometimes  enormously,  but  pale  and  evidently 
edematous.  In  the  course  of  hours  the  edema  subsides. 
Scarification  is  recommended.  The  writer  has  been  able 
to  relieve  the  few  instances  seen  by  him  by  long-continued 
massage  of  the  sides  of  the  neck.  Suprarenal  solution 
might  deserve  a  trial. 


CHAPTER   XIX. 

PERITONSILLAR   ABSCESS   OR    QUINSY.— RETRO- 
PHARYNGEAL  ABSCESS. 

139.  Peritonsillar  abscess,  also  known  as  quinsy,  or 
deep  or  phlegmonous  tonsillitis,  begins  like  ordinary 
acute  tonsillitis,  with  or  without  lacunar  exudation.  On. 
the  first  day  no  distinction  can  be  made  between  it  and 
acute  tonsillitis  in  many  cases.  In  some,  however,  the 
systemic  disturbances  begin  with  less  abruptness  than  in 
simple  tonsillitis.  The  fever  may  decline  within  a  day 
or  two,  but  does  not  disappear  until  the  abscess  opens. 
The  local  discomfort  increases  steadily.  After  one  or 
two  days  the  patient  has  a  constant  feeling  of  fulness  in 
the  throat,  with  a  sense  of  oppression,  embarrassing  the 
breathing  subjectively.  This  distress  interferes  with 
sleep.  There  may  or  may  not  be  visible  dyspnea.  The 
moderate  pain  becomes  intense  upon  swallowing  and  pre- 
vents eating.  Characteristic  is  an  enormous  secretion  of 
clear  mucus  in  the  pharynx.  The  voice  is  peculiarly 
"  thick"  and  somewhat  nasal,  but  not  so  "dead"  as  in 
blockage  of  the  nasophar^'ux.  The  tonsillar  swelling 
shows  on  the  outside  of  the  neck.  The  cervical  glands 
are  usually  palpable. 

Quinsy  is  more  often  one-sided  than  bilateral.  On  in- 
spection the  reddened  and  enlarged  tonsil  is  seen  pro- 
jecting toward  the  middle  line  or  even  beyond.  There  is 
distinct  swelling  in  front  of  the  anterior  pillar  and  in  the 
soft  palate  above  the  tonsil.  After  the  lapse  of  five  to  nine 
days  a  spontaneous  perforation  occurs,  usually  through 
the  soft  palate,  about  i  cm.  above  and  inward  from  the 
tonsil.  The  symptoms  now  subside,  and  within  half  to 
one  day  complete  relief  is  obtained.  About  three  days 
later  the  disease  is  ended. 

234 


PERITONSILLAR    ABSCESS   OR   QUINSY.  235 

Quinsy,  much  less  common  than  tonsillitis,  may  occur 
at  any  age,  but  least  often  in  childhood.  It  is  clearly  a 
pyogenic  infection,  evidently  entering  through  the  tonsil. 
It  is  doubtful  whether  it  ever  occurs  except  in  subjects 
with  some  tonsillar  hypertrophy.  Its  determining  con- 
ditions are  unknown.  Recurrences  in  subsequent  years 
are  not  uncommon.  •  The  exact  seat  of  the  abscess  has 
not  been  determined  by  autopsies.  It  is  not  within  the 
tissue  of  the  tonsil,  but  external  to  it. 

Notwithstanding  the  severity  of  its  symptoms  quinsy  is 
scarcely  ever  followed  by  complications,  even  on  the  part 
of  the  ear.  In  enfeebled,  decrepit  subjects  the  abscess  may 
extend  and  perforate  into  the  external  meatus  of  the  ear. 
Under  such  circumstances  death  may  occur  from  pyemia 
or  septicemia,  especially  on  extension  into  the  mediasti- 
nal space. 

The  rational  treatment  is  the  evacuation  of  the  pus. 
No  other  measures  give  any  relief,  but  until  distinct 
pointing  of  the  abscess  is  visible  the  surgeon  can  never 
be  sure  of  striking  the  pus.  Yet  the  attempt  must  be 
made  even  with  the  chances  against  its  success.  The 
surface  can  be  anesthetized  by  the  prolonged  application 
of  a  pledget  wet  with  cocain  solution  (20  per  cent.). 
Sometimes  a  blunt  probe  thrust  into  the  supratonsillar 
fossa  will  reach  the  abscess.  If  this  fails,  a  knife  may 
be  thrust  into  the  most  prominent  part  of  the  soft  palate, 
directed  outward  and  backward.  The  anatomy  of  the 
large  vessels  must  be  remembered,  but  they  would  only 
be  endangered  by  carelessness  or  unnecessarily  deep  in- 
cisions. Incisions  through  the  tonsils  generally  fail  to 
reach  the  pus.  If  the  operator  does  not  succeed,  he  may 
try  again  daily  until  the  pus  can  escape.  No  further 
treatment  is  required.  After  recovery  a  painstaking  ab- 
scission of  the  tonsil  should  be  made,  to  guard  against 
future  recurrences  of  peritonsillitis. 

140.  Phlegmonous  inflammation  underneath  the 
lingual  tonsil  has  been  reported  by  several  observers, 
evidently  a  rare  occurrence.     In   connection   with   the 


236  RETROPHARYNGEAL   ABSCESS. 

systemic  effects  of  pyogenic  infection  a  painful  swelling 
develops  in  the  region  of  the  lingual  tonsil,  with  intense 
distress.  The  choking  feeling  is  so  intense  that  trache- 
otomy has  been  found  necessary  in  rare  instances.  Re- 
lief is  at  once  obtained  upon  spontaneous  escape  of  the 
pus  or  incision. 

141.  Retropharyngeal  Abscess. — Purulent  exuda- 
tion or  infiltration  into  the  loose  areolar  tissue  behind 
the  pharynx  is  a  disease  moderately  common  in  infancy 
and  early  childhood,  but  quite  infrequent  in  later  life. 
There  are  two  forms,  different  in  significance  and  in 
treatment.  The  acute  abscess  is  a  pyogenic  infection  of 
self-limited  duration,  and  serious  only  by  its  possible 
sequels,  while  the  chronic  or  cold  abscess  is  the  conse- 
quence of  and  indicates  tuberculosis  of  the  cervical 
vertebrae. 

The  acute  abscess,  it  is  claimed,  starts  from  infection 
of  the  retropharyngeal  lymph-glands  situated  between 
the  pharynx  and  the  spinal  column.  Some  suppurative 
process  in  the  nose  or  upper  pharynx,  idiopathic  or  part 
of  an  eruptive  fever,  furnishes  the  virus.  The  retro- 
pharyngeal inflammation  begins  sometimes  suddenly 
with  acute  fever ;  more  often  it  is  of  gradual  onset. 
When  the  abscess  is  situated  above  the  level  of  the 
palate,  it  interferes  with  nasal  respiration  in  the  same 
manner  as  swelling  of  the  pharyngeal  tonsil.  When 
located  lower,  it  may  not  block  nasal  breathing,  but  it 
produces  dyspnea,  especially  intense  if  low  enough  to 
press  against  the  larynx.  The  lower  the  swelling,  the 
greater  is  the  obstacle  to  swallowing  and  the  pain  pro- 
duced thereby.  Stiffness  of  the  neck  is  common  and 
due  to  muscular  rigidity.  After  the  lapse  of  four  to 
eight  days  spontaneous  perforation  occurs,  which  usually 
results  in  recovery.  In  debilitated  infants  the  infection 
may  spread  into  the  posterior  mediastinal  space  and 
cause  fatal  septicemia.  Pneumonia,  perhaps  due  to 
aspiration  of  escaping  pus,  has  also  been  observed. 

The  abscess  can  be  seen  as  a  more  or  less  circumscribed 


TREATMENT.  237 

swelling  on  tlie  posterior  wall  of  the  pharynx,  usually 
one-sided,  and  hence  asymmetric.  Only  in  exceptional 
instances  does  the  diagnosis  require  palpation  of  the 
space  above  the  palate  by  the  finger. 

The  treatment  consists  in  an  incision.  In  most  in- 
stances this  can  be  done  satisfactorily  by  cutting  into  the 
swelling  on  the  posterior  pharyngeal  wall  with  a  knife 
with  a  short  blade.  Surgeons  of  a  former  generation 
used  the  finger-nail.  Too  small  an  opening  may  have  to 
be  reopened.  In  extensive  retropharyngeal  phlegmons 
some  surgeons  practise  an  opening  from  the  outside 
behind  the  sternomastoid  muscle,  of  course,  under  general 
anesthesia. 

142.  The  tubercular  retropharyngeal  abscess  is  of  slow 
development  and  indefinite  duration.  It  is  not  certain 
whether  it  is  ever  due  to  tuberculosis  of  the  retropharyn- 
geal lymph-glands  without  disease  of  the  vertebrae.  In 
its  symptoms  it  resembles  the  acute  abscess,  but  lacks  the 
acuity  of  the  latter.  A  large  exudate  may  ultimately 
break  spontaneously,  sometimes  with  recovery,  more 
often,  however,  ending  in  secondary  infection.  The 
ultimate  prognosis  depends  on  the  course  of  the  verte- 
bral disease.  The  most  successful  treatment  is  aspiration 
through  a  thick  needle  and  injection  of  iodoform  glycerin 
emulsion.  This  should  be  repeated  as  soon  as  the  abscess 
refills. 


CHAPTER   XX. 

CHRONIC    PHARYNGITIS.— CHRONIC   TONSILLITIS 
(PHARYNQOMYCOSIS)  (SUPPURATIVE  PHARYNGITIS). 

143.  The  description  of  chronic  pharyngitis  is  beset 
with  difficulties  on  account  of  the  variety  of  clinical 
pictures  which  this  disease  may  present  in  different  sub- 
jects. There  is  much  confusion  both  in  the  nomencla- 
ture and  classification  given  b}-  text-books.  Some  pre- 
sent the  subject  under  a  number  of  subheads,  giving  the 
impression  of  separate  disease  types,  which  in  reality  do 
not  conform  with  actual  experience.  Practically,  chronic 
pharyngitis  must  be  considered  as  an  extension  of,  or  the 
pharyngeal  equivalent  of,  chronic  rhinitis.  As  a  rule,  it 
is  associated  with  simple,  hypertrophic,  or  purulent  nasal 
inflammation.  Occasionally  it  is  observed  without  co- 
existing nasal  disease,  because  the  latter  has  ended  in 
recovery.  In  such  instances  the  lesions  are  limited  to 
the  faucial  or  lingual  tonsil.  As  in  hypertrophic  rhini- 
tis, we  must  distinguish  between  the  inflammation  of  the 
lining  membrane  and  its  hypertrophy.  Either  lesion 
may  exist  alone,  especially  in  the  case  of  the  tonsils,  but, 
as  a  rule,  both  are  combined.  Morbid  appearances  may 
be  limited  to  the  tonsillar  surface  or  other  small  areas,  or 
may  be  diffuse,  extending  throughout  the  entire  pharynx. 
The  intensity  of  the  visible  inflammation  also  varies  con- 
siderably in  different  instances. 

144.  Chronic  tonsillitis  shows  itself  by  a  redness  of 
the  tonsillar  surface  extending  always  over  the  anterior 
pillars.  The  amount  of  tonsillar  swelling  is  ver>'  varia- 
ble. The  tonsils  may  be  nearly  of  normal  size  or  enor- 
mously hypertrophied.  Mere  hypertrophy,  however, 
although  the  sequel  of  inflammation,  is  not  active  in- 
flammation, and  an  enlarged  tonsil  may  be  perfectly  pale 

238 


CHRONIC    PHARYNGITIS. CHRONIC    TONSILLITIS.  239 

and  present  no  evidence  of  irritation.  Tonsils  in  a  state 
of  chronic  inflammation  often  present  a  very  ragged 
appearance. 

Inflamed  tonsils  frequently  show  characteristic  whitish- 
yellow  specks  or  plugs  retained  in  the  crypts.  Some- 
times these  specks  are  visible  on  inspection ;  in  other 
instances  they  must  be  sought  with  the  probe.  After 
attaining  a  certain  size  (3  to  5  mm.)  they  usually  pop  out 
spontaneously.  They  are  of  very  offensive  odor,  of 
which  the  patient  sometimes  complains,  and  their  pres- 
ence may  taint  the  breath.  They  consist  of  masses  of 
bacilli,  apparently  a  pure  culture  of  an  unidentified 
species.  Small  hard  concretions  of  phosphate  of  lime 
are  found  in  the  tonsil  in  rare  instances.  Not  so  uncom- 
mon are  yellowish  submucous  spots,  minute  abscesses  in 
tonsillar  follicles,  without  any  tendency  to  extension. 

145.  The  lingual  tonsil  is  often  the  seat  of  persistent 
inflammation,  but  only  after  the  period  of  adolescence.  It 
appears  reddened  and  swollen,  and  the  individual  nodules 
are  sometimes  much  enlarged,  resembling  a  cauliflower 
growth.  There  may  be  a  continuous  bridge  of  hyper- 
trophied  adenoid  tissue  from  one  tonsil  to  the  other 
across  the  base  of  the  tongue. 

146.  In  chronic  pharyngitis  enlarged  follicles  of  lym- 
phatic tissue  are  often  seen  on  the  posterior  wall  in  the 
form  of  red  prominences  of  the  size  of  a  pea.  This  ap- 
pearance has  been  termed  granular  pharyngitis^  but  all 
forms  of  transition  occur  between  this  and  other  varieties. 

147.  A  very  striking  and  usually  very  annoying  form 
of  hypertrophied  adenoid  tissue  may  occur  in  the  form 
of  folds  of  mucous  membrane  on  the  lateral  wall  of  the 
pharynx  back  of  the  posterior  pillars.  In  extreme  cases 
they  appear  as  vertical  reddish,  wing-shaped  ledges,  pro- 
jecting from  the  sides  of  the  pharynx  and  receding 
toward  the  roof 

148.  Chronic  inflammation  of  the  pharyngeal  mucous 
membrane  is  not  always  accompanied  by  much  redness. 
The  surface  may  appear  of  normal  color,  but  when  the 


240  CHRONIC    PHARYNGITIS. CHRONIC   TONSILLITIS. 

membrane  is  thrown  into  folds  during  the  act  of  gagging, 
its  thickening  is  apparent.  Intense  \^ascularity  of  the 
posterior  wall  associated  with  great  irritability  is  some- 
times seen  in  patients  with  nasal  stenosis  or  nasal  sup- 
puration. The  most  pronounced  instances  are  found 
only  in  habitual  smokers  and  drinkers,  scarcely  ever  in 
women.  In  this,  as  well  as  in  other  forms  of  chronic 
pharyngitis,  dilated  veins  may  be  observed.  Varicose 
veins,  too,  are  sometimes  seen  on  the  tongue,  in  the 
region  of  the  lingual  tonsil.  Even  circumscribed  varices 
of  the  size  of  a  pin-head  may  be  found.  These  are  at 
times  the  source  of  bleeding,  which  may  raise  a  wrong 
suspicion  of  pulmonary  disease.  In  chronic  pharyngitis 
the  uvula  is  occasionally  elongated.  There  has  been  too 
much  importance  attached  to  this  by  various  writers.  It 
has  been  claimed  that  the  elongated  uvula  touches  the 
tongue  while  the  mouth  is  closed  and  causes  mechanical 
irritation.  This  is  true  only  in  extreme  instances.  In 
moderate  elongation  of  the  uvula  nothing  is  gained  by 
its  amputation. 

149.  The  complaints  in  chronic  phar>'ngitis  are  as 
variable  as  the  clinical  appearances.  They  depend  some- 
what on  the  individual,  as  well  as  on  the  character  of 
the  lesions.  Often  there  are  no  subjective  annoyances. 
Many  patients,  especially  men,  are  annoyed  most  by  the 
viscid  mucous  secretion  dropping  into  the  throat.  This 
is  due  to  the  coexisting  retronasal  catarrh  which  usually 
complicates  the  different  manifestations  of  pharyngitis. 
It  is,  hence,  really  a  concomitant  symptom  of  nasal 
origin.  Viscid  mucous  secretion  is  also  produced  in  the 
region  of  the  pharyngeal  tonsil,  but  neither  on  the  sur- 
face of  the  lower  part  of  the  pharynx  nor  by  the  mucous 
lining  over  the  faucial  tonsils.  Some  mucus,  however, 
may  be  secreted  in  the  region  of  the  lingual  tonsil,  and 
the  presence  of  this  gives  rise  to  hawking  and  clearing 
of  the  throat. 

The  voice  suffers  commonly  in  consequence  of  pharyn- 
gitis.    There  is,  at  least,  quick  fatigue  on  attempting  to 


SYMPTOMS.  241 

sing.  Moreover,  the  larynx  becomes  involved  so  fre- 
quently in  slight  chronic  inflammation  in  consequence 
of  pharyngitis  that  the  singing  ability  may  be  consider- 
ably impaired.  The  vocal  cords  are  very  often  found 
permanently  congested.  Still,  noticeable  exceptions  may 
be  observed. 

Chronic  pharyngitis  by  itself  produces  no  pain.  There 
are,  however,  frequent  subacute  exacerbations  of  inflam- 
mation lasting  a  few  days,  during  which  there  may  be 
more  or  less  soreness.  Apart  from  these  subacute  attacks, 
patients  complain  frequently  of  an  uncomfortable  tired,  irri- 
tated, "raw"  feeling.  Considerable  tickling  may  be  felt, 
especially  when  the  lingual  tonsil  is  involved.  A  very 
distressing  feature  in  chronic  pharyngitis  are  occasionally 
sensations  of  psychic  origin.  There  is  sometimes  a  dis- 
tinct pain  started  during  a  subacute  exacerbation,  or  in 
consequence  of  traumatism, — for  instance,  on  swallowing 
a  fish-bone, — and  this  pain  will  apparently  persist  after  its 
original  cause  has  ceased.  In  others  the  sensation  is  de- 
scribed as  an  irritation  or  oppression  rather  than  as  a  pain. 
The  most  striking  example  of  these  sensations  of  psychic 
origin  is  the  globus  hystericus — a  feeling  of  a  lump  rising 
in  the  throat  and  threatening  choking.  The  subjects  of 
these  fictitious  sensations  are  not  always  hysteric  patients: 
they  may  be  persons  with  normal  nervous  system,  but  of 
emotional  and  self-observing  disposition.  These  fictitious 
sensations  probably  always  have  a  material  origin  at  the 
start,  but  are  kept  up  by  undue  attention  even  after  the 
lesion  producing  them  has  long  been  healed.  They 
cannot  be  influenced  by  any  form  of  treatment  except 
suggestion.  Sensible  people  may  be  cured  by  being 
assured  of  the  harmlessness  of  these  fictitious  sensations. 
Undue  attention  given  by  overanxious  physicians  may 
prove  a  serious  obstacle  to  their  cure. 

150.  The  various  lesions  of  chronic  pharyngitis  give 
rise  at  times  to  distressing  reflexes.  The  most  common 
of  these  is  cough.  This  may  be  due  to  a  concomitant 
bronchitis   or  laryngitis,  or  it   may  depend  entirely  on 

16 


242  CHRONIC    PHARYNGITIS. CHRONIC    TONSILLITIS. 

the  sensitiveness  of  the  inflamed  areas  in  the  upper 
throat,  and  disappear  with  their  successful  treatment.  It 
is  common  in  hypertrophy  of  the  lingual  tonsil.  The 
pharyngeal  irritability  may  lead  to  retching  or  even 
vomiting.  This  is  particularly  started  from  the  inflamed 
lingual  tonsil  or  the  congested  posterior  wall.  The  morn- 
ing vomiting  of  drinkers  depends  in  part  upon  the  pharyn- 
geal irritability. 

Chronic  pharyngitis  has  an  indefinite  duration.  Like 
chronic  rhinitis,  it  is  subject  to  fluctuations  dependent 
partly  on  exposure  to  inclement  weather.  Subacute  ex- 
acerbations are  quite  common.  Under  favorable  hygienic 
surroundings  the  disease  may  cease  to  annoy  the  patient, 
but  rarely  disappears  entirely,  except  upon  radical  change 
of  climate. 

Ear  complications  are  very  common  in  chronic  pharyn- 
gitis, and  probably  depend  more  upon  the  condition  of 
the  nose  than  upon  that  of  the  pharynx.  Such,  at  least, 
seems  the  conclusion  based  upon  the  results  of  treatment. 
Extension  to  the  larynx  is  also  very  common. 

151.  The  treatment  of  chronic  pharyngitis  must  begin 
with  a  cure  of  the  nasal*  condition  present,  even  if  the 
patient  is  not  annoyed  by  his  rhinitis.  As  long  as  the 
nasal  passage  remains  diseased,  only  a  very  imperfect 
and  transient  improvement  can  be  obtained  by  pharyngeal 
treatment.  The  removal  of  a  nasal  stenosis  or  suppura- 
tion, together  with  hygienic  management,  often  suffices 
to  restore  the  patient's  comfort.  Smoking  and  drinking 
must  be  restricted  or  even  forbidden  when  the  character- 
istic congestion  of  the  mucous  membrane  indicates  its 
harmfulness.  The  stomach,  bowels,  and  cutaneous  circu- 
lation must  receive  attention  (compare  1  14  to  1 17). 

Although  gargling  reaches  the  pharynx  but  to  a  very 
limited  extent,  the  writer  cannot  but  admit  the  utility  of 
gargling  with  a  sulphate  of  zinc  solution  (0.5  per  cent), 
as  judged  by  its  effects  upon  the  vascularity  and  the  irri- 
tability of  the  pharyngeal  membrane.  The  use  of  sprays 
of  this  solution  as  well  as  of  other  agents  has,  on  the  whole, 


TREATMENT.  243 

proved  disappointing.  When  there  is  much  vascularity, 
considerable  improvement  may  be  obtained  by  brushing 
the  inflamed  surfaces  of  the  tonsillar  region  or  the  poste- 
rior wall  with  Loffier's  solution  (T[  25).  In  spite  of  the 
temporary  irritation  produced  thereby,  many  patients 
recognize  subjectively  its  beneficial  influence.  It  may  be 
continued  as  a  daily  application  for  several  weeks.  Ni- 
trate of  silver  solutions  (10  per  cent.),  formerly  much  in 
vogue,  have  not  proven  so  satisfactory  in  the  writer's 
experience,  except  when  applied  to  the  lingual  tonsil. 
From  the  various  other  astringents  recommended  in  text- 
books the  writer  has  seen  less  decided  effect  than  from 
the  use  of  Loffler's  solution. 

When  there  is  much  hypertrophy  of  adenoid  tissue, 
surgical  measures  are  necessary.  Large  tonsils  should 
be  removed.  A  description  of  the  technic  will  be  found  in 
1  182.  For  the  cure  of  the  offensive  concretions  in  the 
tonsillar  crypts  slitting  of  these  pockets  has  been  recom- 
mended. A  blunt  hook  is  inserted  and  pulled  through. 
The  author"  has  not  seen  as  good  a  result  from  mere  slit- 
ting as  from  obliteration  of  the  crypts  by  means  of  a 
hook-shaped  galvanocaustic  burner.  The  burning,  if 
limited  to  a  few  lacunas  at  a  time,  causes  very  little  in- 
flammatory reaction.  In  order  to  attain  success,  the  bur- 
ner must  be  inserted  into  the  bottom  of  the  pocket. 

When  the  lingual  tonsil  is  much  hypertrophied,  me- 
dicinal applications  are  not  equal  to  surgical  removal, 
even  though  they  give  transient  benefit.  Prominent 
lymphatic  nodules  on  the  tongue  can  be  snared  off"  or  de- 
stroyed with  a  burner.  Very  large  prominences  may  be 
removed  with  a  curved  guillotine-shaped  knife  (Fig.  j^^. 

The  enlarged  lymph-follicles  on  the  posterior  wall  of 
the  pharynx  have  formerly  received  more  attention  than 
they  deserved.  As  a  rule,  their  persistence  does  not 
interfere  with  comfort  after  the  causative  nasal  lesions 
have  been  eliminated.  When  very  large  or  persistently 
inflamed,  the  follicles  may  be  destroyed  by  inserting  a 
pointed  burner  into  the  central  crypt.     An  awkward  and 


244  CHRONIC    PHARYNGITIS. — CHRONIC    TONSILLITIS. 

rebellious  lesion  is  the  hypertrophy  of  the  lateral  strands 
of  adenoid  tissue,  the  lateral  cords  of  the  pharynx.  While 
they  do  not  shrink  much  upon  the  application  of  Loffler's 
solution  or  other  astringents,  the  irritation  caused  by 
them  may  subside.  When  prominent,  they  are  too  large 
to  be  influenced  by  superficial  burning,  while  snaring  is 
usually  impossible  on  account  of  their  shape.  In  extreme 
cases  they  may  be  amputated  by  means  of  cutting  forceps, 
which,  however,  leaves  a  painful,  slowly  healing  wound. 
Amputation  of  the  elongated  uvula  is  of  much  less  ser- 
vice than  would  appear  from  the  teaching  of  some  text- 
books. It  is  useful  only  when  the  uvula  exceeds  a  length 
of  2^  cm.  While  it  can  be  done  in  a  simple  manner 
with  scissors,  the  resulting  wound  is  quite  painful  for  a 
number  of  days,  as  the  stump  heals  by  granulation  and 


Fig.  73. — Myles'  lingual  tonsillotome. 

moves  with  every  motion  of  the  palate.  A  few  instances 
of  disagreeable  hemorrhage  have  been  described  in  con- 
sequence of  this  operation. 

153.  Pharyngomycosis  is  a  relatively  rare  disease, 
characterized  by  the  presence  of  small  white  spots  on 
the  pharyngeal  lining  without  surrounding  inflammation. 
The  spots,  from  the  size  of  a  pin-head  to  that  of  a  grain, 
appear  as  white  tufts  on  apparently  normal  mucous  mem- 
brane. They  are  most  frequently  seen  in  crypts  of  the 
tonsils,  less  often  on  the  follicles  on  the  posterior  wall  or 
in  the  crypts  of  the  lingual  tonsil.  There  may  be  a  few 
or  many  of  these  spots.  The  white  projecting  tufts  are 
very  firm  and  cannot  be  completely  removed  with  forceps. 
Microscopically,  they  consist  of  interlaced,  branching 
filaments  of  leptotrix,  a   fungus  normally  found  in  the 


SUPPURATIVE    PHARYNGITIS.  245 

mouth,  especially  on  the  teeth,  and  usually  classified, 
although  with  questionable  propriety,  among  the  bacte- 
ria. But,  as  Heryng  has  shown,  the  parasitic  invasion 
is  really  a  secondary  phenomenon,  while  the  primary 
lesion  is  proliferation  and  keratous  degeneration  of  the 
epithelium  of  the  crypts  from  unknown  causes.  The 
disease  has  hence  also  been  termed  hyperkeratosis  lacu- 
naris. 

The  disease  often  causes  no  symptoms,  merely  frighten- 
ing the  patient  by  the  appearance.  Sometimes  moderate 
local  irritation  is  produced  by  it.  As  a  rule,  it  disappears 
spontaneously  in  the  course  of  months  or  a  few  years. 
The  spots  can  be  removed  with  a  certainty  only  by  deep 
punctiform  burns  with  the  galvanocaustic  burner.  If  no 
symptoms  are  produced,  there  is  no  reason  for  any  thera- 
peutic interference. 

SUPPURATIVE   PHARYNGITIS. 

153.  Pathologic  and  therapeutic  considerations  de- 
mand that  suppurative  pharyngitis  should  be  considered 
apart  from  the  other  forms  of  pharyngeal  inflammation, 
although  it  may  be  associated  with  hypertrophic  lesions. 
The  only  pharyngeal  area  from  which  pus  is  secreted  is 
the  region  of  the  pharyngeal  tonsil  at  the  roof  of  the 
pharynx.  Purulent  secretion  is  not  observed  clinically 
from  any  other  part  of  the  pharyngeal  lining.  The 
presence  of  pus  in  the  lower  pharynx  does  not  establish 
the  diagnosis  of  suppurative  pharyngitis,  as  the  secretion 
originates  much  oftener  from  within  the  nose  than  from 
the  pharyngeal  roof.  The  diagnosis  can  be  made  only 
by  seeing  the  pus  at  the  vault  of  the  pharynx  in  the  mir- 
ror. Even  in  the  latter  case  the  pus  may  come  from  the 
sphenoid  sinus  or  posterior  ethmoid  cells.  Suppurative 
pharyngitis  is,  besides,  often  associated  with  some  form 
of  purulent  rhinitis. 

Purulent  secretion  may  be  found  in  connection  with 
moderate  hypertrophy  of  the  pharyngeal  tonsil  in  children. 
Although  of  a  chronic  nature,  there   may  be  complete 


246  SUPPURATIVE   PHARYNGITIS. 

intermissions  in  the  course  of  this  form  of  suppurative 
pharyngitis  during  mild  weather.  When  the  enlarged 
pharyngeal  tonsil  persists  after  puberty,  it  undergoes  a 
sclerotic  change,  and  is  then  much  less  likely  to  form 
pus.  Hence  in  adults  suppurative  pharyngitis  is  more 
commonly  observed  without  enlargement  of  the  pharyn- 
geal tonsil.  In  the  class  of  cases  mentioned  the  secretion 
is  that  of  thick,  yellowish  green,  but  fluid  pus.  In 
another  variety  of  the  disease  the  secretion  is  more  scant 
and  dries  in  the  form  of  adherent  crusts  dislodged  with 
some  difiiculty.  The  surface  underneath  is  found  red- 
dened and  often  slightly  excoriated;  rarely,  thickened. 
This  variety  of  disease,  not  very  common  in  general,  is 
extremely  rare  in  childhood.  It  resembles  ozena  in  the 
character  of  the  secretion.  The  comparison  is  also  borne 
out  by  the  spaciousness  of  the  pharynx  often  observed. 
The  mucous  membrane  may  even  present  an  atrophic 
appearance,  as  judged  by  the  naked  eye.  But  the  specific 
odor  of  ozena  is  lacking  except  when  this  form  of  pharyn- 
gitis is  combined  with  true  nasal  ozena. 

The  complaints  refer,  in  the  first  place,  to  the  secretion. 
It  is  especially  when  dry  crusts  form  that  patients  are 
irritated  by  their  presence  and  make  forcible  efforts  to 
dislodge  them,  sometimes  finishing  by  retching.  The 
crusts  seem  to  form  only  once  in  from  one  to  three  days. 
Their  presence  may  cause  reflex  symptoms,  such  as 
coughing  and  headache  referred  to  the  occipital  region. 

154.  Pharyngeal  suppuration  is  usually  due  to  a  dif- 
fuse inflammation  of  the  mucous  membrane  in  the  area 
of  the  pharyngeal  tonsil.  When  the  tonsil  is  enlarged 
enough  to  be  prominent,  there  is  no  method  of  perma- 
nently arresting  the  process,  except  by  the  operative 
removal  of  the  adenoid  tissue.  But  as  seen  in  adults 
without  thickening  of  the  pharyngeal  lymphatic  tissue, 
the  suppuration  may  be  stopped  by  other  means.  Quite 
often  the  persistent  removal  of  the  secretion  by  the  post- 
nasal douche  will  lead  to  a  cure  in  the  course  of  some 
weeks.     An  atomizer  with  curved   pharyngeal  tip  may 


TREATMENT.  24/ 

prove  equally  efficient  if  properly  used.  When  these 
means  do  not  suffice,  the  writer  has  succeeded  at  times, 
but  not  invariably,  by  brushing  the  pharyngeal  vault 
with  nitrate  of  silver  solutions  (20  to  30  per  cent.)  or 
Loffler's  solution.  Due  care  must  be  used  not  to  spread 
these  irritant  fluids  over  the  adjacent  surface,  for  which 
purpose  the  palate  may  be  held  by  means  of  a  broad  re- 
tractor. When  the  pharyngeal  disease  accompanies  puru- 
lent rhinitis  or  suppuration  of  a  sinus,  the  nasal  lesion 
must  be  cured  before  the  pharyngitis  will  yield  to  treat- 
ment. 

155.  A  peculiar  pathologic  basis  has  been  claimed  by 
Tornwaldt  for  many  cases  of  suppurative  pharyngitis, 
especially  those  in  which  crusts  are  observed.  He  at- 
tributes the  disease  to  an  inflammation  localized  in  the 
pharyngeal  bursa,  which,  he  claims,  is  a  deep  persisting 
recess  of  embryologic  significance.  Neither  his  anatomic 
notions  nor  his  clinical  data  have  received  full  confirma- 
tion by  other  observers.  The  bursa  is  not  a  constant, 
and  rarely  a  deep,  sinus,  and  others  who  have  sought  for 
this  localized  inflammation  have  not  found  it  so  typical  a 
disease  as  Tornwaldt  asserted.  It  must  be  admitted,  how- 
ever, that  the  clefts,  and  especially  the  central  cleft  be- 
tween the  ridges  of  the  pharyngeal  tonsil,  may  be  the  seat 
of  a  persistent  suppuration,  and  that  occasionally  types 
of  pharyngeal  disease  are  found  which  correspond  to  Torn- 
waldt's  description.  Tornwaldt  claims  to  have  cured  his 
patients  by  cauterization  of  the  diseased  recess  with  a 
bead  of  nitrate  of  silver  or  by  the  insertion  of  tire  galvano- 
caustic  burner.  In  those  cases  where  pus  can  be  seen  to 
issue  from  clefts  in  the  pharyngeal  tonsil,  I  have  occa- 
sionally found  this  mode  of  treatment  successful. 

156.  A  lesion  not  rarely  found  in  the  pharyngeal  ton- 
sil are  cysts  with'  purulent  contents,  the  result  of  suppu- 
ration confined  to  a  lymph-follicle.  They  may  be  of  the 
size  of  a  pea  or  larger,  and  produce  symptoms  of  pharyn- 
geal irritation.  They  are  removed  by  abscission  of  the 
tonsil  (1 174). 


248  PHARYNGITIS    SICCA. 

157*  A  form  of  pharyngeal  disturbance  formerly  de- 
scribed as  "pharyngitis  sicca,"  or  "atrophic  pharyngitis," 
must  be  mentioned,  although  it  is  not  a  real  pharyngitis. 
The  mucous  membrane  looks  pale,  dry,  apparently 
atrophic,  and  is  covered  with  a  varnish-like  clear  secretion 
dried  on  the  surface.  The  appearance  results  from  puru- 
lent rhinitis  or  sinuitis,  and  with  the  cure  of  the  nasal 
suppuration  the  pharyngeal  lining  recovers  its  normal 
condition. 


CHAPTER   XXI. 

HYPERTROPHY   OF  THE    PHARYNGEAL  TONSIL  OR 
ADENOID   VEGETATIONS. 

158.  The  frequent  occurrence  of  hypertrophic  lym- 
phatic tissue  at  the  vault  of  the  pharynx  had  been 
entirely  overlooked  until  W.  Meyer  described  this  im- 
portant condition  in  1869.  Yet  it  is  a  very  frequent  and 
very  noticeable  disturbance.  In  various  school  examina- 
tions it  has  been  found  to  exist  in  from  5  to  9  per  cent, 
of  all  children.  No  race  and  no  country  seem  to  be 
exempt.  Its  existence  since  historic  times  has  been 
made  probable  by  Meyer  by  finding  the  characteristic 
facial  expression  indicative  of  it  in  various  portraits  from 
the  middle  ages  and  even  in  some  statues  of  antiquity. 

The  direct  consequence  of  enlargement  of  the  pharyn- 
geal tonsil  is  obstruction  of  nasal  breathing  to  an  extent 
proportionate  to  the  space  occupied  by  the  new  growth — 
and  hence  inversely  proportionate  to  the  dimensions  of 
the  pharynx.  On  account  of  the  vascularity  of  the 
lymphatic  tissue  its  size  is  subject  to  fluctuations.  While 
a  moderate  enlargement  may  be  inappreciable  during 
erect  posture,  the  increased  blood  supply  during  the 
reclining  posture  may  entirely  prevent  nasal  breathing. 
The  obstruction  is  also  increased  during  sleep  by  the 
accompanying  turgescence  of  the  posterior  ends  of  the 
turbinals.  Still  more  noticeable  is  the  obstruction  when 
an  acute  coryza  increases  the  congestion.  The  patient 
hence  sleeps  with  the  mouth  open,  and  snores  whenever 
he  lies  on  his  back,  although  while  awake  he  may  be 
able  to  breathe  through  his  nose  (except  in  high  degrees 
of  hypertrophy).  When  there  is  secretion,  which  often 
occurs  in  this  trouble,  the  child  cannot  blow  his  nose, 

249 


250  HYPERTROPHY    OF    THE    PHARYNGEAL   TONSIL. 

but  draws  the  pus  back  iuto  the  pharynx.  Enlargement 
of  the  pharyngeal  tonsil  also  betrays  itself  by  its  influ- 
ence on  the  voice,  which  becomes  "  dead  "  and  loses  its 
resonance.  The  nasal  sounds  "m"  and  "n"  are  espe- 
cially interfered  with;  the  former  ("  m  ")  sounding  like 
"b,"  the  latter  ("n  ")  like  "d."  An  excellent  descrip- 
tion of  the  speech  in  high  degrees  of  adenoid  vegetation 
is  given  by  Dickens  in  his  character  Barney,  in  Oliver 
Twist.  It  is  only  in  complete  obstruction  of  the  nose  by 
a  severe  corj^za  or  polypi  that  the  same  mode  of  speech 
is  heard. 

159.  The  interference  with  nasal  breathing  results  in 
the  course  of  time  in  thickening  of  the  lips  and  sink- 
ing in  of  the  sides  of  the  nostrils.  These  peculiarities, 
together  with  the  open  mouth,  give  these  children  a 
very  characteristic  "stupid"  expression,  accentuated  by 
a  "dreamy"  look  due  to  vascular  fulness  of  the  lower 
eyelid,  whereby  the  lid-space  is  reduced  in  aperture.  In 
well-marked  instances  the  expression,  as  well  as  the 
voice,  suggests  a  positive  diagnosis.  The  characteris- 
tic appearance  has  been  termed  the  "adenoid  habitus." 
In  many  cases  the  obstruction  of  the  nasopharyngeal 
space  is  accompanied  by  changes  in  the  shape  of 
the  hard  palate,  which  at  first  becomes  merely  arched 
to  an  abnormal  degree.  After  the  second  dentition, 
however,  its  form  often  changes  to  a  V-shaped  or 
Gothic  arch,  while  the  lateral  teeth,  especially  cuspids 
and  bicuspids,  may  incline  inward  instead  of  pointing 
straight  downward.  The  changes  in  the  palate  and 
alveolar  process  are,  however,  not  absolutely  character- 
istic of  enlarged  pharyngeal  tonsil.  Children  with  en- 
larged pharyngeal  tonsils  are  very  prone  to  "take  cold." 
They  get  fresh  nasal  catarrh  from  slight  exposure,  and  it 
often  remains  chronic  during  the  inclement  season  or 
even  longer.  Purulent  secretion,  however,  when  pres- 
ent, is  always  due  to  a  complicating  inflammation  of 
the  nose  or  of  the  pharyngeal  tonsil  itself^often  very 
persistent,  but  it  is  not  a  symptom  resulting  from  mere 


SYMPTOMS.  251 

hypertrophy  of  this  structure.  In  typical  instances  it 
may  be  entirely  absent.  In  the  less  pronounced  forms 
of  hypertrophy  of  the  pharyngeal  tonsil  there  is  often 
the  copious  mucopurulent  discharge  described  in  1  35  as 
the  "scrofulous"  form  of  purulent  rhinitis. 

If  the  adenoid  vegetations  are  not  removed,  a  hyper- 
trophic condition  of  the  turbinals,  especially  the  posterior 
ends,  as  well  as  septal  overgrowth,  are  very  often  found 
in  older  children.  Hypertrophy  of  the  pharyngeal  tonsil 
is  often  accompanied  by  enlargement  of  the  faucial 
tonsils.  They  are  generally  deep  seated  between  the 
pharyngeal  pillars,  and  hence  do  not  apparently  project 
far  into  the  mouth  as  compared  with  their  actual  size. 

160.  The  ears  suffer  in  a  large  proportion  of  cases  of 
adenoid  vegetations.  The  most  common  condition  is  that 
of  catarrh  limited  to  the  Eustachian  tube,  which  form  gives 
the  least  unfavorable  prognosis.  More  serious  are  attacks 
of  purulent  inflammation.  Serous  catarrh  of  the  middle 
ear  is  not  common  in  younger  children,  but  not  so  rare 
in  the  period  preceding  and  following  puberty.  As  a 
rule,  the  ears  are  involved  in  consequence  of  some  tran- 
sient acute  or  subacute  inflammation,  and  not  merely  on 
account  of  the  mechanical  presence  of  the  enlarged  ton- 
sil. The  tonsillar  hypertrophy,  however,  is  the  import- 
ant determining  condition,  without  which  the  temporary 
coryza  or  pharyngitis  would  scarcely  endanger  the  ear. 
While  the  ear  affections  yield  to  the  usual  local  treat- 
ment, relapses  are  almost  sure  to  occur  unless  the  hyper- 
trophied  tonsil  is  removed.  Hence  with  neglect  the 
hearing  may  become  permanently  damaged, 

A  common  complaint  of  children  with  adenoid  vegeta- 
tion is  cough.  Generally  this  is  due  to  frequent  and 
often  persistent  attacks  of  bronchitis  following  acute 
nasopharyngeal  inflammation.  In  other  instances  it 
seems  to  be  a  reflex  disturbance  without  lesions  in  the 
lower  respiratory  passages. 

161.  Children  with  marked  pharyngeal  obstruction 
not  merely  look  stupid,  but  often  are  so.     They  find  it 


252  HYPERTROPHY    OF    THE    PHARYNGEAL   TONSIL. 

difficult  to  concentrate  their  attention.  This  mental 
sluggishness  has  been  termed  aprosexia.  Headaches — 
referred  to  the  back  of  the  head — are  not  uncommon 
during  inflammatory  exacerbations.  Asthenopic  com- 
plaints,— difficulty  in  the  use  of  the  eyes, — fatigue,  and 
strain  are  sometimes  complained  of.  I  have  seen  a  fair 
number  of  instances  in  which  low  degrees  of  far-sighted- 
ness or  astigmatism  annoyed  the  children  sufficiently  to 
necessitate  glasses,  which  could  be  discarded  after  the 
pharyngeal  operation — which,  of  course,  does  not  change 
the  structure  of  the  eye  itself.  The  interference  with 
nasal  respiration  disturbs  sleep.  Such  children  are  often 
restless  at  night,  toss  about  or  wake  with  nightmare  or 
frightening  dreams.  Nocturnal  incontinence  of  urine  is 
also  not  uncommon.  Groenbeck  observed  it  26  times  in 
198  cases.  In  about  one-half  of  the  instances  this 
annoyance  ceases  at  once  after  the  operation.  In  most 
of  the  others  it  improves  gradually.  The  cervical  lymph- 
glands  are  frequently  enlarged.  How  large  a  proportion 
of  such  indurated  glands  is  tubercular  has  not  been 
determined.  In  high  degrees  of  pharyngeal  obstruction 
the  children  may  present  a  stunted  growth  and  marked 
insufficiency  of  weight.  The  dependence  of  this  im- 
paired nutrition  upon  the  blockage  of  the  pharyngeal 
space  is  often  shown  by  the  satisfactory  increase  in  the 
rate  of  growth  following  operation. 

163.  Attention  has  also  been  directed,  especially  by 
earlier  French  surgeons  (Dupuytren,  Chassaignac)  to  de- 
formities of  the  chest  observed  in  children  having  large 
tonsils.  It  is  partly  a  constriction  of  the  lower  part  of 
the  chest  as  compared  with  the  dimension  of  the  upper 
part,  partly  a  flattening  of  the  thorax  in  the  lateral 
diameter,  with  undue  prominence  of  the  sternum — the 
so-called  pigeon-breast.  Whether  these  conditions  are 
not  dependent  on  the  coexistence  of  rickets  is  perhaps 
an  open  question.  Undoubtedly,  however,  the  interfer- 
ence with  breathing  and  the  resulting  violent  exertion 
of  the  diaphragm,  together  with  undue  pressure  of  the 


SYMPTOMS.  253 

external  air  upon  the  yielding  infantile  thorax  during  in- 
spiration, account  for  the  occurrence  of  these  deformi- 
ties. The  respiratory  obstacle  is,  however,  not  so  much 
due  to  the  enlarged  faucial  tonsils,  as  was  formerly  be- 
lieved, as  to  the  blockage  of  the  pharynx  by  the  adenoid 
vegetations,  which  the  earlier  observers  had  not  recog- 
nized. Among  my  patients  in  this  country,  where  rickets 
is  not  a  frequent  disease,  I  have  seen  but  little  of  these 
chest  deformities,  and  never  in  a  very  pronounced  degree. 
Although  most  of  the  disturbances  due  to  enlargement  of 
pharyngeal  tonsil  are  of  mechanical  origin  and  are  hence 
pronounced  in  proportion  to  the  degree  of  enlargement  or 
its  relative  bulk  compared  with  the  (variable)  size  of  the 
pharynx,  still  at  times  even  very  moderate  growths  will 
give  rise  to  much  interference  with  nutrition  (Harrison 
Allen).  I  have  sometimes  seen  improvement  in  the 
general  health  of  children  that  seemed  out  of  proportion 
to  the  small  amount  of  adenoid  tissue  shown  by  the  ope- 
rative removal. 

The  pernicious  influence  of  adenoid  vegetations  upon 
the  blood  (anemia)  shows  itself  by  a  poverty  in  red  glob- 
ules and  hemoglobin,  with  absolute  increase  of  mononu- 
clear and  eosinophile  leukocytes  and  lymphocytes,  while 
after  the  operation  there  is  a  gradual  return  to  the  nor- 
mal condition  of  the  blood  (Lichtwitz  and  Sabrazes). 

163.  While  the  enlargement  of  the  pharyngeal  tonsil 
is  an  affection  of  childhood,  it  does  not  necessarily  dis- 
appear at  puberty.  Sometimes  the  respiratory  obstacle, 
with  all  its  resulting  disturbances,  lasts  during  middle 
life.  As  a  rule,  however,  the  pharyngeal  space  grows 
during  the  second  decade  of  life  at  a  faster  rate  than  its 
adenoid  tissue,  and  the  latter  often  undergoes  partial 
involution.  This  is  evident  by  the  rotundity  which  the 
surface  of  the  enlarged  gland  presents  in  adults,  compared 
with  the  coxcomb-shaped  irregularities  of  the  surface  in 
earlier  childhood.  Hence,  after  adolescence  the  mechani- 
cal interference  with  breathing  subsides  somewhat  as  a 
rule.     Yet  secondary  hypertrophic  changes  in  the  nasal 


254  HYPERTROPHY    OF    THE    PHARYNGEAL   TONSIL. 

walls  and  Eustachian  tubes,  and  hence  liability  to  fre- 
quent inflammatory  attacks  of  nose,  ears,  or  bronchial 
tubes,  are  apt  to  persist  after  adolescence  as  the  sequel 
of  juvenile  adenoids. 

164.  The  diagnosis  of  enlarged  pharyngeal  tonsils 
can  be  made  with  much  certainty  in  more  pronounced 
cases  on  noting  the  facial  expression  and  the  character- 
istic speech.  If  inspection  shows  no  obstruction  in  the 
nose  itself,  the  cause  of  the  respiratory  interference  must 
be  in  the  upper  pharynx.  With  the  exception  of  rare 
cases  of  excessive  enlargement  of  the  posterior  ends  of 
the  turbinal,  or  the  still  rarer  occurrence  of  fibroid  tumors 
in  the  pharynx,  the  lesion  will  be  found  to  be  enlarge- 
ment of  the  pharyngeal  tonsil.  The  diagnosis  is  con- 
firmed by  examination  with  the  finger.  The  surgeon 
presses  the  cheek  between  the  teeth,  so  as  to  keep  the 
mouth  open  and  prevent  the  child  from  biting,  and  there- 
upon inserts  the  finger  through  the  mouth  into  the  upper 
pharynx  by  sliding  in  behind  the  palate,  and  observes 
the  resistance  met  with  in  feeling  for  the  upper  rim  of 
the  nasal  passage.  In  normal  instances  the  relatively 
resisting  posterior  wall  and  roof  are  recognizable  by  touch, 
and  the  space  will  be  found  clear.  When  the  adenoid 
tissue  is  enlarged,  a  soft  cushion  can  be  felt  lining  the 
pharynx  and  encroaching  upon  its  caliber.  As  a  rule, 
too,  the  finger  gets  bloody.  The  surgeon  may  be  misled 
as  to  the  amount  of  adenoid  hypertrophy  in  case  the  body 
of  the  first  cervical  vertebra  is  exceptionally  prominent  in 
the  pharynx. 

The  digital  examination  is  very  disagreeable  to  the 
patient.  In  the  case  of  tolerant  children  a  mirror  ex- 
amination may  be  attempted  instead  of  palpation.  Im- 
practicable under  the  fourth  year,  it  is  quite  feasible  in 
many  older  children,  especially  after  they  have  passed 
the  seventh  year.  A  partial  view  may  also  be  obtained 
by  direct  inspection  on  retracting  the  palate  with  a  hook 
and  throwing  the  head  back  to  the  utmost  extent.  In 
younger  children    the  surface  of  the   enlarged  gland  is 


DIAGNOSIS.  25$ 

irregular.  There  are  coxcomb-shaped  ridges  running 
anteroposteriorly,  usually  six  in  number,  sometimes  more 
by  reason  of  branching  or  less  by  coalescence  of  the 
ridges.  Most  of  the  illustrations  in  text-books  showing 
tufts  and  cauliflower-shaped  projections  are  fanciful  and 
do  not  correspond  to  what  is  actually  seen.  As  pu- 
berty is  approached  the  involution  of  the  adenoid  tissue 
smoothens  the  surface  and  the  growth  is  more  likely  to 
appear  as  a  semiglobular  cushion  relatively  hard.  The 
pharyngeal  tonsil  is  to  be  considered  pathologically  large 
whenever  its  outlines  are  recognizable  as  an  elevation 
above  the  level  of  the  surface,  since  when  perfectly  nor- 
mal, the  edge  of  the  adenoid  area  slopes  so  gradually  as 
to  be  distinguishable  from  the  rest  of  the  mucous  surface 


a  b  c 

Fig.  74. — Enlarged  pharyngeal  tonsils  removed  in  one  piece  by  the  author's 
adenotome  (actual  size) :  a,  From  a  child  four  years  old;  b,  from  a  child  eight 
years  old ;  c,  from  a  young  man  twenty  years  of  age. 

only  by  its  slightly  darker  tint  and  ridged  and  furrowed 
surface.  Normally  there  appears  a  clear  space  of  a  few 
millimeters  between  the  front  end  of  the  adenoid  cushion 
and  the  upper  rim  of  the  choanae.  The  more  the  tonsil 
is  enlarged,  the  more  does  it  project  over  the  upper  rim 
of  the  bony  frame  of  the  nose,  while  in  pronounced  cases 
it  covers  the  entire  posterior  choanae  in  the  postrhino- 
scopic  image.  The  enlarged  gland  can  sometimes  be 
seen  by  direct  inspection  on  retracting  the  palate  forcibly 
with  a  hook,  while  the  head  is  thrown  backward. 

165.  The  structure  of  the  enlarged  pharyngeal  tonsil  is 
that  of  the  normal  gland  with  all  its  elements  uniformly 
increased.     In  earlier  childhood  the  tissue  is  soft,  due  to 


256  HYPERTROPHY    OF    THE    PHARYNGEAL   TONSIL. 

a  preponderance  of  lymph-cells.  As  involution  progresses 
the  growth  becomes  harder,  as  felt  by  the  knife  in  cutting 
it.  This  depends  on  the  gradual  increase  of  the  fibrillar 
elements,  with  corresponding  reduction  in  the  number 
of  lymph-cells.  Not  uncommonly  some  of  the  follicles 
undergo  suppuration  and  change  into  miniature  abscesses. 
The  size  of  the  growth  may  in  extreme  cases  amount  to 
about  6  to  8  c.cm.,  attaining  the  bulk  of  a  walnut.  Its 
attachment  is  always  central,  and  does  not  extend  laterally 
into  the  fossae  of  Rosenmiiller  (Fig.  74). 

166.  Etiology. — Enlargement  of  the  pharyngeal  tonsil  is 
the  consequence  of  acute  coryza  in  childhood.  Whenever 
a  continuous  observation  is  possible,  it  can  be  learned 
that  the  respiratory  interference  begins  with  an  attack 
of  cor}'za,  and  persists  after  the  nasal  inflammation  has 
ceased.  Successive  inflammatory  attacks  gradually  lead 
to  the  full  morbid  development  of  the  adenoid  tissue. 
This  usually  begins  during  the  first  years  of  life,  rarely, 
if  ever,  after  the  third,  but  may  continue  to  increase  dur- 
ing subsequent  attacks  of  rhinitis  until  the  period  before 
puberty.  The  possibility  of  adenoid  hypertrophy  depends 
on  a  predisposition,  the  nature  of  which  is  not  understood. 
It  is  often  a  family  trait,  conspicuously  present  in  some 
families,  markedly  absent  in  others.  It  is  favored  by 
small  dimensions  of  the  nose  and  pharynx,  but  is 
strikingly  absent  in  the  spacious  passages  of  subjects 
suffering  from  ozena. 

There  has  been  some  confusion  created  by  descriptions 
correlating  adenoid  vegetations  with  scrofula.  It  is  now 
admitted  that  the  term  scrofula  is  often  used  in  a  vague, 
not  well-defined,  sense.  Some  of  the  characteristics  for- 
merly referred  to  scrofulosis  are  the  direct  consequence 
of  hypertrophy  of  the  pharyngeal  tonsil — viz.,  the  thick 
lips,  the  attacks  of  subacute  purulent  rhinitis,  and  the 
liability  to  purulent  otitis.  All  this  may  occur  in  chil- 
dren in  whom  no  other  evidences  of  scrofula  are  present, 
and  hence  the  diagnosis  scrofula  may  be  incorrectly  made, 
merely  on  account  of  the  presence  of  adenoid  vegetations. 


ETIOLOGY.  257 

On  the  other  hand,  the  pharyngeal  hypertrophy  is  often 
associated  with  true  scrofula,  as  shown  by  the  presence 
of  palpable  tubercular  lymph-glands. 

167.  It  has  been  claimed  that  there  is  some  relation- 
ship between  adenoid  vegetations  and  tuberculosis.  The 
most  positive  assertion  is  attributed  to  Koch  by  Traut- 
mann,  to  the  effect  that  children  with  this  disease  react 
to  diagnostic  tuberculin  injection.  No  one  else  besides 
Koch  (and  Petruschky)  has  made  this  test  on  a  sufficiently 
large  scale.  In  the  writer's  experience  of  more  than 
twenty  years  a  large  number  of  subjects  with  adenoid 
vegetations  during  childhood  have  not  presented  any 
evidence  of  tuberculosis  during  many  subsequent  years 
of  observation. 

Various  recent  researches  have  shown  that  about  5  per 
cent,  of  enlarged  pharyngeal  tonsils  contain  tubercles 
with  tubercle  bacilli.  These  tonsils  differ  in  no  wise 
from  the  appearance  of  non-tubercular  hypertrophies. 
The  tubercular  disease  is  and  remains  entirely  latent. 
The  diagnosis  can  be  made  only  by  the  subsequent  micro- 
scopic examination,  which  shows  the  presence  of  typical 
tubercles  scattered  throughout  the  adenoid  tissue.  In 
most  cases  the  tubercular  infection  is  a  secondary  occur- 
rence, as  shown  by  the  existence  of  tubercular  foci  in 
other  parts  of  the  body.  Indeed,  it  has  been  found  that 
in  tuberculous  cadavers  even  the  not  enlarged  normal 
pharyngeal  tonsil  may  be  the  seat  of  miliary  tubercles. 
It  is  to-day  an  open  question  whether  a  primary  tuber- 
culosis of  the  pharyngeal  gland  does  occur  at  all.  Yet 
while  the  disease  follows  a  latent  course  without  leading 
to  further  changes  in  the  adenoid  tissue,  the  subsequent 
tubercular  infection  of  the  lymph-glands  may  help  to 
spread  the  mischief.  All  these  statements  concerning 
the  occurrence — presumably  secondary — of  latent  tuber- 
culosis and  its  numerical  frequency  apply  to  the  faucial 
tonsils  to  the  same  extent  as  to  the  pharyngeal  tonsil. 
The  results  of  operations  are  just  as  satisfactory  in  the 
case  of  tonsils  subsequently  found  to  be   tubercular,  as 

17 


:iy 


HYPERTROPHY    OF   THE   PHARYNGEAL   TONSIL. 


when  we  deal  with  simple  enlargement  without  tuber- 
culosiSi 

i68.  Treatment. — Every  enlarged  pharyngeal  tonsil 
which  causes  any  symptoms  whatsoever  should  be  re- 
moved by  operation.  It  is  only  when  the  enlargement  is 
discovered  accidentally  and  has  hitherto  caused  no  mani- 
festations that  the  question  of  operation  may  be  left  for  a 
future  time.  The  operation  may  be  said  to  be  free  from 
risk.  There  are  about  half  a  dozen  cases  of  fatal  bleeding 
on  record,  either  in  bleeders  or  in  poorly  nourished  sub- 
jects, not  watched  sufficiently  after  the  operation.  In  the 
case  of  a  bleeder  operated  by  myself,  an  annoying  hemor- 
rhage persisted  for  thirty-six  hours  without  leading  to 
bad  results.  The  hemorrhage  is  always  profuse  momen- 
tarily, amounting  in  exceptional  cases  up  to  50  to  100 
cm.,  but  rarely  persists  long.  Its  persistence  is  generally 
due  to  shreds  incompletely  detached,  and  may  be  stopped 
by  removing  these  shreds.  Plugging  of  the  postnasal 
space  is  very  rarely  required. 

Beyond  a  slight  fever,  apt  to  occur  within  the  next 
twenty-four  hours,  it  is  quite  uncommon  to  see  any 
annoyance  from  the  operation.  Soreness  is  never  pro- 
nounced, often  absent.  The  wound  heals  in  about  a 
week,  during  which  period  there  is  sometimes  some  sup- 
purative discharge.  There  is  no  after-treatment  required 
or  of  any  service. 

169.  Abscission  of  the  hypertrophied  pharyngeal  ton- 
sil removes  promptly  all  the  symptoms  caused  mechani- 
cally by  its  presence,  while  the  remote  consequences  dis- 
appear gradually.  Even  an  incomplete  removal  may  give 
temporarily  ven.^  satisfactory  results.  The  less  thorough 
the  operation  and  the  younger  the  child,  the  greater  the 
liability  to  subsequent  growth;  hence  apparent  relapses 
are  sometimes  observed  which  may  necessitate  a  second 
operation.  A  complete  removal  precludes  relapses.  In 
cases  complicated,  however,  by  intranasal  anomalies, 
stenosis,  purulent  rhinitis,  or  sinus  aflfections  the  benefit 


TREATMENT.  259 

of  the  operation  may  be  masked  by  the  persisting  nasal 
disease. 

170.  It  has  been  much  debated  whether  the  operation 
should  be  done  with  or  without  narcosis.  The  writer's 
experience  has  led  him  to  condemn  narcosis  as  unneces- 
sary in  most  instances.  Hinkel  has  collected  i8  deaths 
from  American  and  English  sources  alone  from  1892  to 
1898  from  operations  on  the  pharyngeal  tonsil  done  under 
narcosis.  This  is  an  appalling  mortality  in  an  operation 
otherwise  devoid  of  risk,  Hinkel  suggests  that  the  de- 
velopment of  the  adenoid  tissue  coexists  often  with  per- 
sistence of  the  fetal  state  of  the  thymus  gland,  the  con- 
dition termed  status  lymphaticus — which  predisposes  to 
sudden  death  from  trivial  causes.  Bromid  of  ethyl  has 
been  lauded  as  a  convenient  substitute  for  chloroform  or 
ether  for  this  operation,  on  account  of  its  quick  and  tran- 
sient anesthesia.  But  statistics  have  shown  that  for 
other  purposes  this  agent  is  not  safer  than  other  anes- 
thetics. 

Narcosis  makes  the  operation  more  formidable  and 
necessitates  more  assistance.  It  does  not  in  any  way 
permit  a  more  thorough  operation,  as  most  of  the  relapses 
which  the  writer  has  seen  had  been  operated  previously 
by  others,  or  by  himself  under  anesthesia.  The  pain  in 
well-arranged  operations  is  not  sufficient  to  necessitate 
the  superfluous  risk  of  an  anesthetic.  It  is  only  in  the 
case  of  unruly  children  from  whom  active  resistance 
must  be  expected  that  narcosis  becomes  necessary.  Nar- 
cosis is  also  preferable  when  the  faucial  tonsils  are  to  be 
excised  at  the  same  sitting,  as  this  triple  operation  is 
usually  too  severe  a  tax  on  a  child's  tolerance.  With 
narcosis  the  head  must  be  pendant  over  the  edge  of  the 
table,  or  the  body  turned  to  one  side.  With  this  pre- 
caution there  is  no  risk  of  blood  entering  the  lower 
air-passages. 

Without  the  narcosis  the  child  is  firmly  held  in  the  lap 
with  its  body  tilted  forward  and  the  head  thrown  back, 
as  this  position  is  the  most  favorable.     The  pain  is  very 


260  HYPERTROPHY    OF   THE    PHARYNGEAL   TONSIL. 

much  reduced  by  the  use  of  a  cotton  pledget  moistened 
with  20  per  cent,  solution  of  cocaiu,  held  in  place  for 
some  two  to  three  minutes.  It  has  seemed  to  the  writer 
that  cocain  auesthesia  is  enhanced  by  the  previous  use 
of  suprarenal  solution,  as  well  as  the  hemorrhage  some- 
what reduced,  but  some  pain  must  be  expected. 

171.  The  easiest,  quickest,  and  most  thorough  mode 
of  operation  is  by  means  of  the  curved  guillotine  devised 
by  Schiitz.  The  writer  had  been  experimenting  along 
the  same  line,  and  devised  a  similar  instrument  with  a 
more  favorable  form  of  handle  (Fig.  75).     The  pharyn- 


FlG.  75. — Author's  adenotome. 


geal  end  of  the  guillotine  is  20  mm.  wide,  the  sweep  of 
the  knife  about  22  mm.  in  length,  and  the  curve  is 
adapted  to  hug  the  entire  roof  and  upper  posterior 
pharyngeal  wall.  The  instrument  is  slid  up  behind  the 
palate,  pushed  upward  and  backward  with  considerable 
force,  and  in  one  sweep  the  knife  removes  the  entire 
adenoid  growth.  By  inadvertence  this  may  be  swallowed 
without  harm.  By  extensive  comparative  trials  the 
writer  has  found  no  other  mode  of  operation  so  thorough, 
so  quick,  so  painless,  and  followed  by  so  little  hemor- 
rhage as  by  means  of  this  instrument.  The  ordinary 
size  of  the  instrument  will  fit  any  child  over  three  to  four 


TREATMENT. 


261 


years  of  age.     A  smaller  size  can  also  be  had.     I^arge 
faucial  tonsils  are  no  real  obstacle  to  its  introduction. 
172.  A  very  popular  instrument  is  the  Gottstein  knife, 
which  should  be  well  sharpened  (Fig.  76).    It  is  intended 
to  slide  in  place  along  the  posterior  edge  of  the  vomer, 


Fig.  76. — Gottstein's  adenoid  knife. 

whereupon  it  is  forcibly  pushed  backward  and  downward. 
Soft  adenoids  are  easily  removed  in  one  sweep.  But  in 
case  of  harder  structures  of  older  children,  the  knife  is 
more  apt  to  slip  than  the  guarded  blade  of  a  guillotine. 
It  may  have  to  be  inserted  repeatedly  until  the  finger 
finds  the  space  clear. 


Trautmann's  sharp  spoon. 


The  Trautmann  sharp  spoons  or  curets  (Fig.  •]']\  made 
in  three  sizes,  although  very  efficient,  have  been  super- 
seded by  the  broader  Gottstein  knife.  They  often  fail  to 
remove  the  entire  gland,  while  causing  considerable 
hemorrhage. 

173.  A  postnasal  cutting  forceps  for  the  adenoid  opera- 


FiG.  78. — Author's  adenoid  forceps. 


tions  was  originally  devised  by  Loewenberg.  As  his 
model  was  too  clumsy  and  withal  its  blade  too  small, 
the  writer  constructed  a  forceps  of  sufficient  size  to 
grasp  the  entire  tonsil  (Fig.  78).  The  upturned  part  is 
17  mm.  high,  and  the  curved  cutting  blade  extending 


262 


HYPERTROPHY    OF    THE    PHARYNGEAL   TONSIL. 


through  the  arc  of  a  circle  has  a  total  length  of  15  mm. 
Yet  it  will  rarely  remove  the  entire  gland  in  one  piece, 
although  three  or  four  successive  cuts  can  clear  the  space 
very  perfectly.  The  lateral  spring-guards  originally  in- 
tended to  prevent  the  pieces  from  falling  into  the  larynx 
have  been  found  unnecessary.  In  my  former  experience 
I  found  it  advantageous  to  supplement  the  work  of  this 
form  of  forceps  by  the  subsequent  introduction  of  another 
forceps  cutting  transversely,  so  as  to  reach  the  extreme 
lateral  end  of  the  growth  (Fig.  79). 


•■^. 


Fig.  79. — Adenoid  forceps  cutting  in  the  anteroposterior  direction 


174*  Some  surgeons  use  the  cold  snare  through  the 
mouth  either  with  a  straight  or  a  slightly  curved  cannula. 
This  causes  relatively  little  bleeding,  but  must  be  re- 
applied quite  often,  in  order  to  remove  the  entire  tonsil. 
At  the  best,  it  is  an  uncertain  and  tedious  mode  of  operat- 
ing, although  not  very  painful.  The  writer  can  rec- 
ommend it  only  for  small  remnants  left  by  previous 
incomplete  operations,  especially  in  older  subjects  who 
can  tolerate  the  pharyngeal  mirror. 

The  snare  put  through  the  nose  is  even  more  uncertain 
in  its  action  and  very  disagreeable.  The  operation  was 
done  originally  by  Meyer  by  means  of  a  ring-shaped 
curet  put  through  the  nose  vertically  and  then  turned 
horizontally.    This  method  has  been  entirely  abandoned. 


TREATMENT.  263 

The  so-called  simple  method  of  scratching  oflf  the  vege- 
tations by  means  of  the  finger-nail  is  still  occasionally 
mentioned  by  writers.  It  is  thoroughly  unsurgical  and 
entirely  inefficient  when  the  tonsil  is  of  firm  structure. 
The  use  of  a  sharp  steel  shield  over  the  end  of  the  fin- 
ger— the  artificial  nail — can  likewise  not  compete  with 
the  use  of  properly  designed  instruments. 

175.  In  any  form  of  operation  except  by  means  of  the 
curved  guillotine  used  with  sufiicient  pressure  there  is  a 
possibility  that  some  fragments  may  be  left.  If  these 
are  of  'any  size,  a  recurrence  of  the  growth  is  possible  in 
younger  children.  Partially  detached  shreds  may  cause 
a  persistent  hemorrhage.  Unless  examination  of  the 
excised  tonsil  or  its  fragments  gives  assurance  that  the 
operation  has  been  thoroughly  done,  the  pharynx  should 
be  explored  by  the  thoroughly  sterilized  finger.  It  is, 
however,  difficult  to  recognize  small  remnants  of  the 
gland  immediately  after  the  operation.  During  the 
following  five  to  seven  days  any  remaining  bits  of  ade- 
noid tissue  are  swollen  by  reason  of  traumatic  inflamma- 
tion, and  bleed  freely  when  disturbed.  If  any  remnants 
of  the  tonsil  are  detected  after  the  lapse  of  a  week,  they 
should  be  removed  by  the  use  of  cutting  forceps  or  the 
cold  snare. 

No  medicinal  treatment  has  any  influence  upon  an 
enlarged  pharyngeal  tonsil.  Cauterization — chemical  or 
thermic — is  inefficient  and  dangerous  to  the  ear. 


CHAPTER  XXII. 

HYPERTROPHY  OF  THE  FAUCIAL  TONSILS. 

176.  Enlargement  of  the  faucial  tonsils  is  even  more 
common  than  excessive  growth  of  the  phar\'ngeal  tonsil. 
It  begins  in  early  childhood,  rarely  later  than  about  the 
tenth  year  of  life,  and  remains  unchanged  during  subse- 
quent development.  The  protrusion  of  the  enlarged 
tonsil  is  either  inward  or  outward.  In  the  former  case 
the  tonsil  protrudes  into  the  fauces  as  a  more  or  less 
globular  body.  In  the  latter  case  the  adenoid  cushion 
spreads  out,  but  remains  more  or  less  hidden  between  the 
pillars,  and  finds  room  for  its  overgrowth  by  crowding 
the  tissues  outward  and  somewhat  upward.  In  extreme 
instances  of  this  type  the  tonsil  may  scarcely  protrude 
while  the  palatal  muscles  are  at  rest.  But  its  large  size 
is  shown  by  corresponding  prominence  during  the  act  of 
gagging.  Most  commonly  the  tonsil  grows  both  inward 
and  outward.  The  projection  of  the  hypertrophied  tonsil 
may  be  very  unequal  on  the  two  sides,  but  when  an  out- 
ward growth  occurs,  it  involves  usually  the  two  tonsils  to 
a  symmetric  extent.  The  enlarged  tonsil,  when  not  in- 
flamed, is  pale.  The  orifices  of  its  crj'pts  are  very  dis- 
tinct. Large  tonsils  are,  however,  often  in  a  state  of 
chronic  inflammation,  especially  during  childhood,  and 
present  a  redness  which  extends  over  the  adjoining  part 
of  the  palate  and  anterior  pillar. 

177.  Hypertrophy  does  not  change  the  typical  struc- 
ture of  the  tonsil.  All  its  constituent  elements  are 
uniformly  involved.  During  the  earlier  period  the  en- 
larged tonsil  is  soft  and  quite  vascular.  Upon  the  appli- 
cation of  cocain  such  a  tonsil  shrinks  very  decidedly  in 
size.  Later  on  many  enlarged  tonsils  undergo  a  fibrous 
change  and  become  harder,  with  a  predominance  of  the 

264 


HYPERTROPHY   OF  THE   FAUCI AL  TONSILS.  265 

connective  tissue  and  stroma  over  the  lymphoid  cells. 
Although  these  harder  tonsils  are  less  vascular,  the  fibril- 
lar sclerosis  involving  the  arterial  walls  may  lead  to  trou- 
blesome hemorrhage  during  operations  on  account  of 
imperfect  retraction  of  the  vessels. 

178.  The  morbid  enlargement  of  the  faucial  tonsils  is 
produced  by  the  same  causes  which  lead  to  hypertrophy 
of  the  pharyngeal  tonsil — viz.,  repeated  attacks  of  coryza 
during  early  childhood.  Hence  enlargement  of  the  fau- 
cial tonsils  is  often,  though  not  invariably,  associated 
with  enlargement  of  the  pharyngeal  tonsil.  On  the  other 
hand,  it  is  rare  to  find  adenoid  vegetations  without  at 
least  some  overgrowth  of  the  faucial  tonsils.  I^arge 
tonsils  are  often  found  without  any  history  of  previous 
throat  inflammations.  But  the  occurrence  of  tonsillitis 
is  an  additional  factor  often  leading  to  further  growth. 
Nasal  stenosis  of  any  kind  seems  also  a  potent  etiologic 
factor. 

A  small  proportion  of  enlarged  tonsils  contains  tu- 
bercles without  any  characteristic  or  distinctive  appear- 
ance during  life.  This  latent  tuberculosis  does  not  reveal 
itself  in  any  way  except  by  the  induration  of  the  cervical 
lymph-glands,  which  is  not  characteristic.  The  state- 
ments made  in  T[  167  concerning  tuberculosis  of  the 
pharyngeal  tonsil  apply  equally  to  the  faucial  tonsils. 
Here,  too,  tubercular  infection  is  mostly,  if  not  always, 
secondary  to  some  other  focus  of  the  disease  somewhere 
else  in  the  body.  Infection  results  most  likely  from 
tubercular  sputum,  but  may  perhaps  be  primary  in  some 
cases  from  the  use  of  tubercular  milk. 

179.  Enlarged  tonsils,  when  not  inflamed,  need  not 
cause  any  symptoms  or  disturbances.  This  is  especially 
true  of  tonsils  which  have  grown  into  the  faucial  space, 
and  which  many  a  patient  retains  to  old  age  without 
suffering  therefrom.  Those  glands,  however,  which,  by 
their  growth,  have  pushed  the  tissues  outward  and  up- 
ward and  are  concealed  between  the  pillars,  may  produce 
mischief  by  their  mechanical  presence.    They  may  cause 


266  HYPERTROPHY  OF   THE  FAUCIAL  TONSILS. 

engorgement  of  the  posterior  ends  of  the  turbinals  suffi- 
ciently to  necessitate  mouth-breathing  with  accompany- 
ing restlessness  during  sleep.  They  may  simulate  the 
presence  of  an  enlarged  pharyngeal  tonsil.  Yet  in  the 
majority  of  cases,  when  symptoms  of  mechanical  origin 
are  referred  to  the  faucial  tonsils,  they  are  really  caused 
by  the  coexisting  enlargement  of  the  pharyngeal  tonsil. 
More  potent  for  mischief  are  large  tonsils  in  a  state  of 
chronic  inflammation,  when  distinctly  and  permanently 
reddened.  In  this  condition  they  may  constitute  the 
essential  lesion  of  so-called  chronic  pharyngitis  and 
account  for  all  the  symptoms  present — viz.,  uncomfort- 
able sensations,  throat  irritation,  and  cough.  Persistently 
reddened  tonsils  are  often  subject  to  periodic  attacks  of 
acute  or  subacute  inflammation.  The  history  of  many 
patients  teaches  that  recurrences  of  acute  tonsillitis  are 
common  until  the  tonsils  are  removed.  Chronically  in- 
flamed tonsils  may  also  help  to  maintain  chronic  disease 
of  the  Eustachian  tube,  even  though  they  represent  but 
one  of  the  factors  involved.  It  is  current  belief,  though 
not  definitely  proven,  that  large  tonsils  increase  the 
liability  to  and  the  danger  of  diphtheria  and  scarlet 
fever. 

i8o.  Treatment. — The  description  of  the  disturbances 
produced  by  enlarged  tonsils  indicates  what  may  be  gained 
by  their  operative  removal.  Tonsils  that  have  caused  no 
symptoms  may  be  let  alone,  but  whenever  any  constant 
or  periodic  disturbance  can  be  referred  to  their  presence, 
the  tonsil  should  be  removed  as  thoroughly  as  possible. 
Abscission  of  a  superficial  slice  is  of  very  little  value. 
The  operation  is  practically  free  from  serious  risk.  Per- 
haps a  few  dozen  cases  of  fatal  hemorrhage  are  on  record 
in  bleeders  or  from  neglect.  Annoying  hemorrhage  is 
not  uncommon,  especially  in  adults  with  hard  tonsils; 
less  so,  in  children.  Primary  hemorrhage  may  be  avoided 
by  the  use  of  the  hot  snare.  But  even  in  this  case  a 
secondary  hemorrhage,  though  very  rare,  is  possible  after 
detachment  of  the  eschar.     There  are  no  large  bleeding 


TREATMENT.  26/ 

vessels,  but  free  oozing  may  occur,  especially  in  hard 
tonsils,  and  is  sometimes  difficult  to  control.  Gargling 
with  tannic  or  gallic  acid  as  recommended  in  text-books 
does  not  check  it.  Pellets  of  ice  are  sometimes  of  benefit. 
More  positive  is  a  tampon  steeped  in  antipyrin  solution 
(lo  per  cent),  dusted  with  tannin,  and  held  firmly  in 
place.  A  tampon  wet  with  Monsell's  solution  of  iron  is 
equally  effective,  but  forms  a  disagreeable,  voluminous 
clot.  Steady  compression  by  means  of  a  plain  tampon 
held  by  forceps  will  often  suffice.  Patience  is  a  neces- 
sary virtue.  Various  clamps  have  been  devised  to  be  left 
in  place  for  hours.  In  very  rare  extreme  cases  it  has 
been  found  necessary  to  tie  the  external  carotid  artery. 

i8i.  Tonsillar  wounds  become  covered  with  a  whitish- 
gray  coating  which  may  resemble  diphtheria.  Super- 
ficial infection  is  probably  inevitable  in  every  case,  but  it 
is  not  common  to  see  any  deeper  or  more  serious  evidence 
of  infection.  Even  when  such  unpleasant  reaction  does 
occur,  it  causes  only  transient  annoyance  and  no  real 
danger.  Tonsillotome  wounds  heal  in  from  five  to  ten 
days,  according  to  their  size.  It  is  not  possible  to  main- 
tain a  tonsillar  wound  aseptic.  The  nearest  approach  to 
it  the  writer  has  found  in  the  free  and  repeated  insuffla- 
tion of  glutol,  which,  however,  adheres  but  incompletely. 
Iodoform  does  not  adhere  at  all.  So-called  antiseptic 
mouth-washes  (compare  1  134)  add  to  the  patient's  com- 
fort during  the  healing  and  control  the  odor  of  the  breath, 
but  do  not  influence  the  wound  to  any  extent.  Tonsillar 
wounds  always  pain  more  or  less,  but  this  pain  can  be 
entirely  controlled  by  the  insufflation  of  orthoform  a  few 
times  a  day. 

Tonsil  operations  require  anesthesia  only  when  active 
resistance  on  the  part  of  the  patient  is  to  be  expected. 
The  pain  is  considerably  reduced,  but  not  entirely 
avoided,  by  free  brushing  with  20  per  cent,  solution  of 
cocain. 

182.  The  simplest  mode  of  operating  is  by  means  of 
the  guillotine,  of  which  there  are  various  patterns  (Fig. 


268 


HYPERTROPHY    OF   THE    FAUCIAL   TONSILS. 


80).  In  all  of  them  a  gliding  spear  drags  the  tonsil 
inward  while  the  knife  cuts.  The  guillotine  must  be 
forcibly  pressed  against  the  pillars  in  order  to  grasp 
enough  of  the  tonsil.  This  operation  is  efficient  when 
a  globular  mass  projects  into  the  faucial  space,  but  it  is 


Fig.  80. — Mathieu's  tonsillotome. 

insufficient  when  dealing  with  a  broad,  flattened  tonsil 
hidden  between  the  pillars.  When  remnants  are  left 
after  the  use  of  the  tonsillotome,  they  may  be  seized  with 
forceps  and  snipped  off  with  long  scissors  or  a  blunt- 
pointed  bistoury.  Indeed,  it  is  not  difficult  to  amputate 
a  projecting  tonsil  simply  by  the  use  of  the  bistoury  and 


Fig.  81. — Author's  hot  snare  for  tonsillotomy. 

traction  forceps,   but   the  operation  cannot  be  done  as 
quickly  as  with  a  tonsillotome. 

183.  In  the  case  of  hard  fibrous  tonsils  in  which  hemor- 
rhage is  feared  (especially  in  adults),  or  when  the  shape  of 
the  gland  does  not  permit  complete  removal  by  the  ton- 
sillotome, the  hot  snare  can  be  used  to  advantage.  As 
most  of  the  galvanocaustic  snares  in  the  market  are  too 


TREATMENT.  269 

fragile,  the  writer  has  designed  a  stronger  instrument  for 
the  removal  of  the  tonsil  (Fig.  8i).  The  tonsil  is  seized 
with  a  double  hook  or  a  vulsella  forceps,  over  which  the 
snare  is  slipped  until  it  grasps  the  tonsil  as  near  as  pos- 
sible to  its  base.  The  wire  is  drawn  tight  while  cold,  and 
heated  to  a  bright-red  glow  only  when  resistance  is  felt  to 
its  further  constriction.  The  resulting  wound  heals  nearly 
as  quickly  as  a  cut  with  a  knife.  No  bleeding  whatsoever 
occurs.  If  necessary,  the  snare  may  be  reapplied  until  no 
projecting  remnants  are  left.  When  the  shape  of  the  tonsil 
does  not  permit  the  snare  to  be  applied,  the  adhesions  of 
the  adenoid  tissue  to  the  pillars  may  first  be  separated  by 
the  use  of  a  hook  or  a  blunt-pointed  knife.  The  grasp  of 
the  snare  may  then  be  facilitated  by  burning  a  shallow 
groove  into  part  of  the  periphery  of  the  tonsil  with  a 


Fig,  82. — Ingals'  tonsil  forceps. 

galvanocaustic  burner.  The  wire  loop  can  now  be  easily 
slipped  into  this  groove.  Special  grasping  forceps  are 
sometimes  useful  (Fig.  82). 

The  cold  snare  is  a  less  cumbersome  instrument  than 
the  galvanocaustic  snare.  It  is  slightly  more  painful, 
however,  and  unless  a  strong  instrument  is  used,  the  wire 
may  not  cut  through,  but  pull  out  of  the  instrument, 
causing  embarrassment.  A  strong  and  apparently  effi- 
cient snare  has  been  devised  by  Peters  (Fig.  83).  The 
cold  snare  does  not  prevent  hemorrhage  with  so  much 
certainty  as  the  hot  wire.  Some  surgeons  have  suggested 
dissecting  out  the  entire  tonsil  by  means  of  a  galvano- 
caustic knife-shaped  burner.  This  is  an  uncalled-for 
mutilation,  leaves  a  large  painful  wound,  often  resulting 
in  irritating  scars,  and  may  give  rise  to  serious  secondary 
hemorrhage. 


270  HYPERTROPHY    OF    THE    FAUCIAL   TONSILS. 

184.  It  is  often  a  serious  question  how  to  deal  with  large, 
deep-seated,  and  not  projecting  tonsils  which  cannot  be 
reached  well  by  any  instrument.  In  the  case  of  very 
young  children,  discretion  is  sometimes  the  better  part 
of  valor.  Inasmuch  as  such  tonsils  do  not  ordinarily 
cause  any  serious  damage  and  usually  shrink  somewhat 
in  the  course  of  time,  it  is  at  times  the  wiser  plan  to  let 
them  alone.  If  an  operation  is,  however,  clearly  indi- 
cated, it  can  be  made  more  thorough  by  removing  the 
deeper  portion  of  the  tonsil  piecemeal  with  any  kind  of 
punch-forceps — for  instance,  my  postnasal  forceps  (Fig.  79), 

Considerable  reduction  in  the  size  of  tonsils  may  be 


Fig.  83. — Peters'  tonsil  snare. 

obtained  by  inserting  a  pointed  burner  into  the  crypts 
and  obliterating  them  gradually.  The  result  is  ultimate 
shrinkage.  If  only  a  few  crypts  are  burned  at  one  sitting, 
there  is  but  very  little  inflammatory  reaction.  Yet  the 
result  in  the  end  is  never  so  satisfactory  as  that  of  a  clean 
amputation  if  the  latter  is  feasible  or  accepted  by  the 
patient. 

Hypertrophied  tonsils  cannot  be  reduced  in  size  by 
medicinal  treatment.  The  swelling  due  to  chronic  inflam- 
mation, however,  may  be  influenced  somewhat  by  the  use 
of  Loffler's  solution.  Its  employment  for  some  weeks  will 
sometimes  render  an  operation  unnecessary.     A  marked 


TREATMENT.  2/ 1 

influence  upon  the  size  of  chronically  inflamed  tonsils  is 
also  exerted  by  the  removal  of  the  hypertrophied  pharyn- 
geal tonsil.  Faucial  tonsils  which  seem  to  indicate 
operation  will  often  become  quiescent  and  harmless  after 
the  successful  removal  of  adenoid  vegetations. 


CHAPTER   XXIII. 

HAY  FEVER— AUTUMNAL  CATARRH. 

185.  Hay  fever  is  an  affection  characterized  by  severe 
nasal  irritation,  usually  extending  to  neighboring  organs 
and  occurring  only  during  a  part  of  the  warm  season,  but 
recurring  annually.  It  may  be  compared  to  a  severe 
coryza  vasomotoria  produced  by  certain  unknown  condi- 
tions existing  only  during  the  summer.  The  attack 
begins  with  itching  of  the  nose,  which  extends  to  the 
eyes  and  often  the  ears.  The  nose  soon  becomes  ob- 
structed, a  part  of  the  time  wholly  occluded.  Periodic 
sneezing  fits  occur,  followed  by  profuse  watery  discharge. 
The  nasal  symptoms,  as  well  as  the  complaints  referable 
to  adjoining  organs,  fluctuate  during  difierent  times  of  the 
day  and  on  different  days.  They  are  usually  made  worse 
by  hot,  dry  weather,  moderated  by  rains  and  cooler  spells. 
A  high  degree  of  nasal  occlusion  causes  a  feeling  of  pres- 
sure in  the  head,  sometimes  headache.  The  eyes  become 
suffiised  with  tears,  blood-shot,  and  the  lids  show  venous 
congestion,  which  may  finally  give  them  a  dusky  hue. 
The  ears  often  become  stuffy,  but  no  permanent  ear 
lesions  are  produced  by  hay  fever.  The  throat  feels 
irritated,  and  more  or  less  severe  coughing  may  follow. 
The  most  distressing  symptom  is  difficult  breathing, 
which  increases  to  periodic  spells  of  asthma,  especially 
at  night. 

On  examination  the  nose  presents  no  appearances  char- 
acteristic of  this  disease  except  edema  of  the  mucous 
membrane,  especially  over  the  turbinals  during  the  height 
of  the  attack.  The  nasal  lining  is  not  injected  except 
when  previously  in  a  condition  of  hypertrophic  rhinitis. 
There  is,  however,  excessive  turgescence  of  all  cavernous 
tissue.     The  surface  is  very  sensitive  to  contact  of  the 

272 


HAY    FEVER AUTUMNAL    CATARRH.  2/3 

probe.  Mechanical  irritation  intensifies  the  attack  and 
starts  the  secretion.  The  discharge  in  typical  cases  is 
a  clear  serum.  Occasionally,  but  rarely,  the  disease  is 
combined  with  a  true  inflammatory  coryza  with  purulent 
discharge.  Whatever  other  lesions  or  anomalies  may  be 
found  are  not  due  to  hay  fever,  but  existed  previously 
and  constitute  a  favorable  predisposing  condition  for  this 
disease.  It  is  quite  common  to  meet  with  septum  de- 
formities, sharp  lateral  crests,  and  circumscribed  hyper- 
trophies of  the  mucous  membrane  or  enlargement  of  the 
pharyngeal  tonsil,  but  all  preexisting  before  the  attack 
came  on. 

After  hay  fever  has  ceased  with  the  end  of  the  warm 
season,  the  patient  has  no  further  nasal  symptoms  ex- 
cept those  due  to  any  existing  lesions  and  anomalies 
independent  of  hay  fever.  The  disease  returns  annually, 
with  an  occasional  exception.  After  many  seasons  it 
sometimes  stops  spontaneously,  especially  on  permanent 
change  of  residence  to  a  more  favorable  locality.  Most 
patients,  however,  do  not  lose  their  annual  affliction. 
In  our  climate  typical  cases  begin  toward  the  end  of 
July  or  middle  of  August,  and  often  on  the  same  day 
each  succeeding  year.  The  affection  stops  at  the  latest 
with  the  first  frost,  in  some  people  indeed  with  the  begin- 
ning of  cooler  weather.  In  less  typical  instances  it  may 
start  earlier  in  the  season,  even  in  June,  or  whenever  the 
weather  gets  warm.  In  these  cases  it  is  likely  to  fluctu- 
ate considerably  with  the  weather,  or  even  to  intermit 
temporarily.  The  less  typical  cases  present  all  gradations 
from  genuine  hay  fever  limited  to  the  summer  months  to 
irregular  spells  of  vasomotor  coryza  brought  on  by  various 
other  modes  of  irritation,  as  well  as  by  warm  weather. 
This  atypical  form  is  known  as  "rose-cold."  In  Eng- 
land and  on  the  Continent  hay  fever  begins  and  ends 
earlier  than  in  America.  The  disease  seems  most  preva- 
lent among  the  English  and  Americans.  It  has  scarcely 
been  observed  in  the  north  and  south  of  Europe.  But 
reports   are    multiplying   concerning   its   occurrence   in 

18 


274  HAY    FEVER —AUTUMNAL    CATARRH. 

Germany  and  France,  The  same  statement  really  applies 
to  our  country  as  well,  and  it  is  an  open  question  whether 
the  disease  is  on  the  increase,  or  whether  physicians  give 
it  more  attention  than  formerly. 

i86.  The  disease  ceases  within  a  few  hours,  or  at  the 
latest  within  a  day,  on  going  to  certain  localities  known 
to  be  immune  against  hay  fever.  Some  parts  of  the 
White  Mountains,  especially  the  village  of  Bethlehem, 
and  the  open  sea  afford  relief  to  all  sufferers.  Many 
other  localities  give  immunity  to  most  patients,  but  not 
to  all.  Strange  to  say,  some  people  may  suffer  in  one 
place  and  find  relief  in  the  other,  while  to  others  this 
boon  is  reversed.  These  favored  spots  are  the  larger 
lakes,  the  upper  Michigan  shore  of  Lake  Michigan,  most 
of  the  shore  of  Lake  Superior,  the  woods  of  Northern 
Michigan,  and  many  of  the  higher  localities  in  the 
Rocky  Mountains.  The  peculiar  seasonal  and  geographic 
distribution  of  hay  fever  has  led  to  the  view  that  it 
is  produced  by  the  inhalation  of  the  pollen  of  grasses 
floating  in  the  air.  In  our  climate  the  pollen  of  the 
universally  distributed  ragweed  is  especially  suspected. 
The  principal  basis  for  this  view  has  been  furnished  by 
the  researches  by  Blackley,  himself  a  sufferer  from  the 
disease.  By  means  of  a  device  resembling  a  rain  gauge 
he  collected  and  counted  the  number  of  pollens  on 
microscopic  slides  exposed  for  a  definite  length  of  time. 
He  found  thus  that  the  beginning  of  the  attack  coincided 
"with  a  certain  increase  in  the  number  of  particles  floating 
in  the  air,  while  the  remissions  during  cooler  or  moist 
weather  coincided*  with  diminished  prevalence  of  the 
pollen.  As  we  do  not  know  any  other  form  of  irritant 
the  seasonal  and  geographic  variations  of  which  explain 
the  etiology  of  hay  fever,  the  pollen  theory  is  at  present 
a  plausible  working  hypothesis.  But  it  cannot  be  said  to 
be  established  definitely.  Blackley  contracted  an  attack 
of  hay  fever  while  on  the  ocean  by  opening  a  package  of 
pollen,  and  thus  apparently  showed  that  these  vegetable 
particles  can  bring  on  the  attack,  yet  this  isolated  case  is 


ETIOLOGY.  275 

scarcely  convincing  on  account  of  the  psychic  factor  in- 
volved. The  fact  that  sufferers  may  get  the  disease  in 
cities  far  distant  from  fields  is  consistent  with  our  knowl- 
edge of  the  wafting  of  dust  over  large  distances.  But  there 
are  a  few  instances  on  record  of  attacks  persisting  on  sea- 
board on  the  ocean  at  distances  over  which  the  land  dust 
is  not  carried.  Perhaps  the  most  difficult  problem  not 
answered  by  the  pollen  theory  is  the  immunity  enjoyed 
by  small  areas, — for  instance,  the  village  of  Bethlehem 
in  the  White  Mountains, — while  neighboring  regions, 
apparently  under  similar  conditions,  do  not  protect 
against  the  disease.  All  the  favored  localities  are  rela- 
tively dust  free,  but  mere  absence  of  dust  does  not  neces- 
sarily protect. 

187.  All  observers  agree  that  some  form  of  predisposi- 
tion is  necessary  in  order  to  contract  the  disease.  It  is 
rare  in  very  young  children,  but  often  begins  after  about 
the  tenth  year.  It  does  not  often  begin  after  the  fourth 
decade  of  life,  but  even  old  age  is  not  entirely  exempt. 
It  is  more  common  in  men  than  in  women.  It  is  a 
disease  almost  limited  to  the  refined  classes,  and  is  hardly 
ever  observed  in  people  below  a  certain  social  status.  A 
person  who  is  poor  and  uneducated  is  practically  proof 
against  this  disease.  This  peculiarity,  as  well  as  the 
recurrence  in  many  on  the  same  day  of  every  year, 
points  to  the  importance  of  psychic  factors,  the  full  role 
of  which  we  cannot  yet  analyze.  Many  patients  present 
a  distinct  neuropathic  taint,  although  pronounced  neu- 
rasthenia and  hysteria  are  not  markedly  predisposing. 
While  the  bulk  of  the  sufferers  are  otherwise  in  good 
health,  anemia  and  convalescence  from  enfeebling  dis- 
eases often  coincide  with  the  first  attack  of  hay  fever. 
Those  in  whom  no  personal  nervous  history  can  be 
elicited  give  usually  evidence  of  nervous  instability  in 
the  family  history.  The  disease  involves  not  rarely 
several  members  of  a  family.  Basing  himself  on  exten- 
sive statistic  inquiry,  Beard  has  termed  hay  fever  a  func- 
tional neurosis.    If  we  understand  by  the  term  neurosis  a 


276  HAY    FEVER AUTUMNAL    CATARRH. 

nervous  disturbance  not  dependent  upon  demonstrable 
change  in  the  nervous  system,  and  not  the  necessary  con- 
sequence of  some  peripheral  lesion,  this  name  is  applic- 
able. We  may  thus  call  hay  fever  a  neurosis  due  to  a 
certain  irritation  of  the  respiratory  mucous  membrane  by 
an  unknown  irritant  in  predisposed  subjects. 

The  predisposition  depends  partly  upon  the  existence 
of  other  nasal  anomalies.  This  is  shown  by  their  fre- 
quent coexistence,  as  well  as  by  the  beneficial  influence 
of  their  elimination.  The  successful  removal  of  septum 
deformities,  of  circumscribed  hypertrophies  of  mucous 
membrane,  and  enlargement  of  the  pharyngeal  and  fau- 
cial  tonsils  or  of  foci  of  suppuration  relieves  some  patients 
markedly  and  occasionally  cures  one  completely. 

188.  Hay  fever  victims  escape  the  disease  by  spending 
the  fatal  season  in  an  immune  locality.  Some  stand  the 
distress  as  long  as  possible  until  the  increasing  heat  forces 
them  to  flee  for  relief  The  sufferers  have  formed  a  hay- 
fever  association  with  headquarters  at  Bethlehem,  which, 
while  it  serves  to  spread  useful  information,  exerts,  on 
the  other  hand,  a  bad  psychic  influence. 

Most  writers  speak  of  the  valuable  influence  of  nerve 
tonics,  arsenic,  zinc  phosphid,  or  valerianate  strychnin, 
etc.,  upon  the  disease,  but  I  cannot  find  a  single  record 
of  any  permanent  cure  obtained  thereby.  The  latest  re- 
ports of  the  Hay  Fever  Association  claim  emphatically 
that  there  are  no  cures  on  record.  On  the  other  hand, 
more  can  be  expected  of  intranasal  surgery  upon  proper 
indications.  The  full  restoration  of  nasal  patency  relieves 
the  suffering  to  a  great  extent,  even  if  it  does  not  prevent 
the  attack.  In  medical  literature  a  number  of  apparent 
cures  are  on  record,  but  they  have  mostly  not  been  fol- 
lowed for  a  sufficient  number  of  successive  seasons  to  be 
fully  convincing.  I  may  say  the  same  of  several  instances 
in  my  own  limited  experience  with  this  disease.  Some 
years  ago  galvanocaustic  destruction  of  the  turgescent 
cavernous  tissue  was  extensively  practised,  apparently 
with  some  relief  during  the  following  season.     But  the 


TREATMENT.  2/7 

records  of  the  Hay  Fever  Association  disclaim  any  per- 
manent cures  obtained  thereby.  During  the  attack  itself 
any  operative  treatment,  except  a  clean  incision  resulting 
in  free  patency  of  the  nose,  gives  rise  to  very  unpleasant 
reaction. 

Decided  temporary  relief  is  obtained  by  the  use  of  a  spray 
of  suprarenal  solution.  This  agent  has  also  been  recom- 
mended for  internal  use,  but  on  questionable  theoretic 
grounds  and  with  very  questionable  results.  In  several 
instances  in  which  hay  fever  coexisted  with  and  seemed 
dependent  upon  purulent  rhinitis  I  have  obtained  an  ap- 
parent cure  for  the  season  by  the  use  of  this  spray,  fol- 
lowed by  the  douche,  and  the  spray  of  watery  solutions 
of  the  essential  oils  (1  25).  The  use  of  cocain  is  too 
transient  to  be  serviceable,  and  the  danger  of  cocain  habit 
too  great  to  sanction  its  employment  by  patients.  The 
asthmatic  attacks  can  sometimes  be  greatly  relieved  by 
antipyrin  internally. 

189.  It  is  instructive  to  compare  the  pathology  of  hay 
fever  with  that  of  another  disease  of  similar  seasonal  and 
geographic  distribution — viz.,  spring  catarrh  of  the 
conjunctiva  of  the  eye.  This  affection  is  not  directly 
related  to  hay  fever.  In  about  15  instances  of  it  which  I 
have  seen  I  have  known  only  one  patient  to  suffer  at  the 
same  time  from  hay  fever.  Its  lesions  are  the  striking 
but  not  constant  grayish  tumefactions  of  the  ocular  con- 
junctiva around  the  cornea,  while  absolutely  constant, 
but  less  noticeable,  are  the  lesions  of  the  conjunctiva  of 
the  upper  lid.  The  disease  begins  during  the  warm  sea- 
son and  ends  with  frost,  but  returns  annually.  Its  symp- 
toms are  irritation  of  the  eyes,  watering,  sensitiveness  to 
light,  and  discomfort  on  use.  The  symptoms  cease  during 
the  cold  season  at  first,  but  in  some  patients  persist  in  a 
very  mild  degree  during  winter  after  a  duration  of  many 
years.  The  first  summer  the  conjunctiva  of  the  upper 
lid  shows  merely  a  mild  degree  of  catarrhal  inflammation 
with  stringy  mucous  secretion.  The  second  season  the 
surface  is  slightly  follicular.     Later  on  the  follicles  en- 


278  HAY    FEVER AUTUMNAL    CATARRH. 

large  and  assume  the  appearance  of  papillse.  During 
winter  the  conjunctiva  is  again  normal,  but  after  a  num- 
ber of  years  the  lesions  diminish,  but  do  not  disappear 
entirely  during  cold  weather,  producing,  however,  very 
little  annoyance.  Like  hay  fever,  spring  catarrh  returns 
with  fatal  regularity  every  year.  As  the  writer  was  the 
first  to  point  out,  a  sufferer  gets  absolute  relief  by  going 
to  a  locality  immune  against  hay  fever.  The  resemblance 
to  hay  fever  is,  unfortunately,  completed  by  the  rebel- 
liousness of  the  disease  to  all  treatment. 


CHAPTER   XXIV. 
DIPHTHERIA.! 

190.  Diphtheria  may  be  defined  clinically  as  an  inflam- 
mation with  the  formation  of  false  membranes,  and  etio- 
logically  as  the  reaction  of  the  tissues  to  infection  by  the 
diphtheria  bacillus.  These  two  definitions  do  not  coincide 
fully.  A  pseudomembranous  inflammation  is  sometimes 
caused  by  other  germs,  while  the  reaction  to  the  diph- 
theria bacillus  may  be  limited  to  a  superficial  inflamma- 
tion without  membranes.  Diphtheria  is  essentially  a  dis- 
ease of  childhood.  Uncommon  within  the  first  few  months 
of  life,  its  maximum  frequency  and  mortality  occur  in  the 
first  five  to  seven  years  of  infancy,  becoming  less  frequent 
and  less  fatal  after  that  period.  It  is  not  frequently  seen 
after  adolescence  and  very  rarely  after  middle  life. 

The  disease  begins  with  fever,  usually  increasing  for  a 
day  and  of  variable  height,  rarely  excessive,  sometimes 
remittent  or  even  absent.  The  fever  lasts  usually  as  long 
as  the  local  lesion.  With  it  there  are  marked  general 
disturbance,  lassitude,  malaise,  want  of  appetite,  furred 
tongue,  and  often  more  or  less  albuminuria.  The  cer- 
vical glands  are  generally  swollen,  and  remain  so  until 
after  recovery.  From  the  start  there  is  pain  on  swal- 
lowing and  sore  throat.  The  affection  begins  most  often 
on  the  tonsils,  generally  on  both  sides,  sometimes  on  the 
posterior  pharyngeal  wall,  rarely  on  the  soft  palate.  The 
invaded  spots  show  a  whitish  coating,  in  the  form  of  a 
membrane,  which  from  the  start  cannot  be  detached  with- 
out leaving  a  bleeding  abraded  surface.     In  severe  cases 

'  It  is  not  within  the  province  of  this  work  to  include  a  complete  descrip- 
tion of  diphtheria,  as  this  disease  is  fully  treated  in  all  text-books  on  general 
medicine.  Hence  details  will  only  be  given  regarding  its  localization  in  the 
upper  air-passages. 

279 


280  DIPHTHERIA. 

the  color  of  the  membrane  may  turn  to  a  dark  brown, 
being  stained  by  blood  extravasation.  Around  the  mem- 
brane is  an  area  of  considerable  redness  and  swelling. 
When  the  tonsils  are  involved,  they  swell.  Except  in 
mild  or  in  properly  treated  cases  the  membranous  inflam- 
mation extends  so  as  to  involve  the  larger  part  of  the  vis- 
ible throat.  It  may  spread  upward  into  the  nasopharynx, 
which  is  rare,  or  even  into  the  nasal  passages.  Much 
more  common  is  the  involvement  of  the  larynx  in  the 
form  of  croup.  The  extension  may  continue  from  two  to 
five  or  seven  days,  rarely  longer.  After  this  period  the 
membranes  gradually  detach  themselves,  and  the  abraded 
surfaces  heal.  When  the  membranes  are  detached  arti- 
ficially, they  form  again  in  a  few  hours.  Occasionally  a 
relapse  or  rather  an  exacerbation  occurs  when  the  disease 
seems  nearly  ended.  In  exceptional  cases  the  persistence 
of  the  disease  for  a  number  of  weeks  has  been  observed. 
In  rare  instances  deep  ulceration  may  follow  after  detach- 
ment of  the  membrane  and  cause  cicatricial  shrinkage 
and  adhesions  in  the  pharynx. 

191.  The  disease  varies  in  severity  with  the  epidemic 
and  with  the  individual.  We  can  distinguish  between 
abortive,  mild,  average,  and  severe  or  septic  cases,  but 
with  transitions  between  these  forms.  The  systemic  dis- 
turbances are  more  or  less  pronounced,  somewhat  in  pro- 
portion to  the  intensity  of  the  local  process.  But  sequels, 
especially  the  different  forms  of  paralysis,  are  nearly  as 
apt  to  occur  in  the  mildest  cases  as  in  the  severe.  The 
contagiousness,  also,  does  not  depend  on  the  severity  of 
the  case.  In  abortive  cases  nothing  is  seen  beyond  an 
apparently  slight  pharyngitis  or  tonsillitis.  The  diagno- 
sis suggested  by  known  exposure  can  be  verified  only  by 
the  bacteriologic  test  or  the  subsequent  occurrence  of 
paralysis.  In  mild  cases  the  typical  membranes  are  seen, 
but  they  do  not  spread  in  extent  after  the  first  or  the 
second  day.  In  the  severe  or  septic  form,  the  severity  of 
which  depends  perhaps  on  concomitant  infection  by 
other  germs,  especially  streptococci,  or  on  want  of  re- 


COMPLICATIONS.  28 1 

sisting  power  of  the  victim,  the  prostration  and  fever 
reach  a  high  degree  from  the  start.  The  membranes 
spread  rapidly  and  extensively  and  are  of  more  than 
ordinary  thickness,  while  the  septic  complication  is 
shown  by  the  intense  foulness  of  the  breath  and  the 
systemic  prostration.  Hemorrhages  into  the  mucous 
membrane  stain  the  membranes  a  dark  brown.  In  such 
severe  instances  the  disease  lasts  longer  and  is  followed 
by  a  more  tedious  convalescence. 

192.  The  mortality  of  diphtheria  varies  considerably 
in  different  years  and  with  the  class  and  age  of  patients. 
Before  the  antitoxin  treatment  was  introduced  the  aver- 
age death-rate  in  hospitals  was  from  30  to  35  per  cent. , 
this  figure  being  much  surpassed  in  children  under  five 
years,  while  adults  gave  a  more  favorable  prognosis.  In 
private  practice  the  death-rate  did  not  generally  exceed 
about  one-half  of  this  figure,  but  fluctuated  in  different 
years.  The  most  common  cause  of  death  is  extension 
into  the  larynx,  resulting  in  suffocation.  In  the  second 
place,  general  sepsis  due  to  streptococcus  complication  is 
to  be  feared.  Bronchopneumonia  carries  off"  a  large  pro- 
portion, especially  in  hospitals.  A  small  number  die 
from  sudden  heart  failure. 

193.  The  recovery  is  complicated  in  a  large  percentage 
of  cases  by  transient  paralysis  of  the  soft  palate.  This 
occurs  about  two  to  three  weeks  after  the  start  and  lasts 
two  to  three  weeks,  always  terminating  favorably.  It 
shows  itself  by  the  passage  of  fluids  or  even  solid  food 
into  the  posterior  choanse  during  swallowing,  and  by  the 
changed  and  diminished  resonance  of  the  voice.  On 
inspection,  the  palate  is  seen  to  hang  flaccid  and  immov- 
able during  intonation.  Somewhat  less  common  is  paral- 
ysis of  the  ciliary  muscle  of  the  eye,  with  complete 
suspension  of  accommodation,  but  without  involvement 
of  the  iris  movements — always  bilateral.  Except  in  the 
case  of  myopia  it  causes  inability  to  read,  while  hyper- 
metropes  who  require  their  accommodation  for  the  dis- 
tance see  blurred  even  in  the  distance.     Like  paralysis 


282  DIPHTHERIA. 

of  the  palate,  it  always  ends  in  spontaneous  recovery  in 
the  course  of  two  to  three  weeks.  The  percentage  of 
these  postdiphtheritic  paralyses  has  risen  since  the  intro- 
duction of  antitoxin  treatment,  on  account  of  the  greater 
number  of  patients  surviving  under  this  treatment. 
More  serious  than  these  localized  affections  is  the  diffuse 
involvement  of  motor  and  sensory  nerves  throughout  the 
body,  of  which  cases  a  small  proportion  end  fatally. 
Diphtheria  of  the  pharynx  and  nose  leads  to  suppurative 
otitis  in  a  moderate  proportion  of  cases. 

194.  The  clinical  description  of  nasal  diphtheria  as  an 
extension  from  the  pharynx  has  been  given  in  1  82. 
While  this  must  be  considered  as  a  very  grave  complica- 
tion, primary  diphtheria  of  the  nose  as  described  in  T[  81 
is  a  remarkably  mild  disease,  often  entirely  afebrile  and 
rarely  leading  to  any  complications.  It  is,  however,  just 
as  contagious  as  other  forms. 

In  a  small  number  of  instances  diphtheria  ascends  into 
the  upper  pharynx  above  the  palate,  probably  always  as 
a  secondary  extension  from  below.  It  may  prove  rather 
persistent  in  this  locality,  causing  mild  systemic  disturb- 
ances, with  nasal  obstruction  and  sniffling  due  to  post- 
nasal secretion.  When  the  postnasal  mirror  cannot  be 
used,  the  diagnosis  is  based  on  obtaining  fragments  of 
membranes  on  exploring  the  region  with  a  cotton-appli- 
cator or  on  the  bacteriologic  test. 

According  to  postmortem  findings,  some  of  the  nasal 
accessory  cavities  are  commonly  infected  during  ordinary 
diphtheria.  The  infection  is  due  to  the  bacillus  of  diph- 
theria in  nasal  diphtheria,  although  even  then  the  in- 
flammation is  not  necessarily  pseudomembranous.  When 
the  process  has  not  reached  the  nose,  the  sinuses  are 
transiently  inflamed,  with  or  without  secretion,  by  reason 
of  the  entrance  of  some  of  the  ordinary  pyogenic 
microbes. 

Recovery  is  followed  by  immunity  lasting  many 
months,  and  often  a  lifetime.  Yet  recurrences  after  the 
lapse  of  a  year  are  sometimes  met  with. 


PATHOLOGY.  283 

195.  Pathology, — The  diphtheritic  process  consists  of  a 
necrosis  of  at  least  the  epithelium,  or  even  of  part  of  the 
mucous  membrane,  to  a  variable  depth,  with  inflammatory 
reaction  in  the  mucous  membrane  underneath.  The  ne- 
crotic tissue  still  in  contiguity  with  living  tissue  becomes 
imbued  with  coagulating  fibrin.  Its  detachment  by 
sloughing  occurs  subsequently  after  the  destructive  action 
of  the  microbes  upon  the  living  tissue  has  come  to  a 
standstill  by  the  resisting  power  of  the  latter.  Patholo- 
gists distinguish  between  croupous  and  so-called  true 
diphtheritic  inflammation.  In  the  former  case  only  the 
epithelium  is  involved,  and  a  firm,  easily  detached  mem- 
brane results.  In  the  latter  type  the  process  is  deeper 
seated  and  the  necrosis  affects  the  mucous  membrane 
underneath  the  epithelium.  Both  forms  of  inflammation 
are  caused  by  the  same  parasite,  the  process  depending 
somewhat  on  the  resisting  power  of  the  tissues  and  more 
so  on  the  locality  affected.  In  the  larynx  it  is  superficial 
croup,  as  a  rule  ;  in  the  nasal  passage  it  may  be  croupous 
or  deeper  diphtheritic  inflammation  ;  in  the  pharynx,  it 
is  generally  true  diphtheritic  inflammation. 

196.  Etiology. — Diphtheria  is  the  result  of  infection  by 
a  specific  microbe,  known  as  the  Klebs-Lofiier  bacillus. 
Its  precise  description  and  cultural  peculiarities  can  be 
found  in  all  bacteriologic  works. ^     It  has  been  found  and 

1  A  short  straight  or  slightly  curved  bacillus,  variable  in  size,  averaging 
about  0.5  to  0.8  11  in  length  hy  y^  fj.  width.  Non-motile.  Many  irregular  club- 
shaped  forms  mixed  with  typical  rods.  Stains  fairly  readily,  especially  with 
alkaline  methylene-blue.  Takes  Gram  stain.  Staining  shows  polar  differentia- 
tion, the  ends  being  more  colored  than  the  center.  Neisser's  stain  applied  to 
fresh  culture  of  diphtheria  bacilli  shows  granules  at  or  near  the  end  of  each  rod 
stained  blue  in  an  isolated  manner.  A  culture  kept  at  35°  C.  for  ten  to  twenty 
hours  is  used.  After  fixation  by  heat  the  cover-slip  is  stained  one  to  three 
seconds  with — 

Methylene-blue  (Gruebler) I 

Alcohol  (96  per  cent.) 20 

Distilled  water .  950 

Glacial  acetic  acid 50 

well  washed  in  water  and  counterstained  three  to  five  seconds  in  vesuvin  solu- 
tion  (1:500  boiling  water).     The  diphtheria  bacillus  grows  readily  in  most 


284  DIPHTHERIA. 

identified  by  observers  in  diphtheria  throughout  the  whole 
world.  About  one-fifth  to  one- fourth  of  the  throat  diseases 
which  suggest  the  clinical  diagnosis  diphtheria  are  really 
due  to  other  germs,  mostly  the  streptococcus.  In  these 
cases  the  specific  bacillus  is,  of  course,  not  found.  How- 
ever much  the  appearances  may  temporarily  resemble  true 
'diphtheria  in  these  instances,  the  clinical  course  is,  as  a 
rule,  not  quite  the  same.  They  are  milder  (except  in 
connection  with  scarlet  fever),  are  less  likely  to  extend 
in  area,  have  a  small  or  no  mortality  (again  excepting 
scarlatinous  angina),  and  are  never  followed  by  paralytic 
sequels.  Clinically,  however,  it  is  often  impossible  to 
distinguish,  at  the  beginning,  between  a  membranous 
angina  due  to  other  germs  and  a  mild  diphtheria.  The 
diphtheritic  bacillus  is  also  not  found  in  true  diphtheria 
if  the  examination  in  a  septic  case  is  made  at  a  late 
period,  when  other  coexisting  parasites  have  crowded  out 

media  and  does  not  liquefy  gelatin.  Thrives  especially  well  in  Loffler's  solid 
serum  (3  parts  blood-serum  with  i  part  bouillon  containing  i  per  cent,  peptone, 
I  per  cent,  grape-sugar,  and  0.5  per  cent.  salt).  On  this  serum  other  microbes 
do  not  grow  as  rapidly  as  the  bacillus  diphtherias,  which  shows,  in  the  incubator, 
round,  moist,  grayish-white  colonies  within  twenty-four  hours,  while  within 
eight  to  ten  hours  the  colonies,  too  small  to  be  seen  by  the  eye,  may  be  exam- 
ined microscopically  on  transferring  them  to  a  cover-slip.  Grows  readily  in 
milk  without  changing  the  appearance  of  the  fluid.  Cultures  and  dried  bacilli 
remain  alive  for  long  periods  of  time.  Killed  by  water  of  60°  C.  inside  of 
half  an  hour,  and  practically  instantaneously  by  boiling  soda  solution. 

Much  confusion  has  arisen  from  the  existence  of  another  bacillus,  the 
pseudo-diphtheria  bacillus  of  von  Hoffmann,  which  resembles  the  true  diph- 
theria bacillus  closely  in  morphology  and  cultural  peculiarities.  A  distinction 
between  the  two  is  certain  only  by  reason  of  the  absolute  harmlessness  of  the 
pseudo  diphtheria  bacterium  to  animals,  and  very  probable  on  careful  comparison 
of  cultures  in  various  media.  According  to  most  observers,  the  pseudo-diph- 
theria bacillus  does  not  show  the  characteristic  polar  granules  with  Neisser's 
stain  applied  to  young  cultures. 

The  pseudo-diphtheria  bacillus  is  found  relatively  often  in  the  normal  throat, 
and  to  some  extent,  too,  in  non-diphtheritic  disease  of  the  pharynx,  but  not 
usually  in  large  number.  On  the  other  hand,  in  true  diphtheria  the  pseudo- 
bacillus  does  not  multiply,  as  a  rule,  and  whenever  tests  on  animals  have  been 
employed,  it  was  found  that  all  the  bacilli  in  real  diphtheria  were  pathogenic. 
Hence  when  a  micro-organism  resembling  the  diphtheria  bacillus  is  found  in 
abundance  in  any  throat  lesion,  the  diagnosis  of  diphtheria  can  be  made  with 
very  little  chance  of  error. 


ETIOLOGY.  285 

the  specific  germ.  Cultural  search  for  the  diphtheria 
bacillus  will  also  fail  if  antiseptics  have  previously  been 
applied  to  the  throat.  But  apart  from  these  apparent 
exceptions  the  Klebs-Loffler  bacillus  is  always  found  in 
genuine  diphtheria,  and  its  presence  or  absence  decides 
the  diagnosis.  Since  the  successful  treatment  of  diph- 
theria is  absolutely  specific,  a  bacteriologic  search  should 
be  made  in  every  case. 

In  stained  cover-slip  preparations  made  by  wiping  the 
membranous  spot  with  a  sterile  rod  the  bacillus  can  be 
detected  in  a  sufficiently  characteristic  form  for  diagnostic 
purposes  in  more  than  50  per  cent.  In  case  of  doubt  a 
culture  is  made  from  the  membrane  by  wiping  it  with  a 
sterile  rod,  with  care  to  prevent  contamination.  On  the 
surface  of  the  serum  recommended  by  Lofiier  the  diph- 
theria bacillus  grows  more  readily  than  most  bacteria 
likely  to  be  found  in  the  throat,  so  that  its  characteristic 
colonies  can  be  detected  with  the  microscope  and  identi- 
fied after  the  lapse  of  eight  to  ten  hours  (in  the  incubator 
or  any  warm  place  of  about  100°  F.).  A  very  convenient 
culture-dish  is  the  flat  covered  tin  box  suggested  by 
Jaques,  its  advantage  being  the  small  bulk,  its  protection 
against  contamination,  and  its  low  cost. 

197.  The  diphtheria  bacillus  has  been  found  by  culture 
a  number  of  times  in  the  normal  throat  of  persons  known 
to  have  been  exposed  to  the  disease.  In  the  case  of  sus- 
ceptible subjects,  especially  children,  its  presence  may 
finally  result  in  delayed  infection.  But  undoubtedly 
many  individuals,  particularly  those  beyond  early  child- 
hood, are  more  or  less  proof  against  the  disease,  and  the 
bacillus  may  exist  in  such  throats  transiently  as  a  surface 
parasite,  harmless  to  the  bearer,  but  a  source  of  danger  to 
others.  In  other  instances  the  germ  causes  a  superficial 
or  very  mild  inflammation  without  the  formation  of  mem- 
branes— the  abortive  cases. 

198.  In  microscopic  sections  of  the  diseased  pharyngeal 
mucous  membrane  the  bacillus  is  found  only  in  and  im- 
mediately underneath  the  false  membrane.     The  appear- 


286  DIPHTHERIA. 

ances  show  positively  that  the  tissue  necrosis  extends  as 
deep  as  the  bacillary  invasion.  By  culture  a  few  isolated 
germs  are  sometimes  found  in  the  viscera  in  fatal  cases. 

The  proof  that  this  parasite  is  the  cause  of  diphtheria 
has  been  completed  by  the  demonstration  of  its  pathogenic 
power  in  animals,  as  well  as  by  the  study  of  the  poison  it 
produces  and  of  the  physiologic  antidote  formed  in  the 
animal  body  against  this  poison.  Inoculation  of  mucous 
membranes  in  animals  (especially  young  animals)  with 
the  isolated  germ  produces  diphtheritic  inflammation, 
however,  without  the  marked  tendency  to  extend  as  it 
does  in  man.  But  the  reaction  to  most  pathogenic  germs 
is  by  no  means  identical  in  different  species  of  animals. 

The  etiologic  significance  of  the  diphtheria  bacillus  is 
supported  by  a  study  of  the  effects  of  its  poisons.  When 
the  culture  fluid  deprived  of  living  germs  is  injected  into 
animals,  the  characteristic  prostration  is  obtained,  ending 
fatally  in  case  of  a  sufficiently  large  dose  and  causing  a 
lingering  cachexia  in  smaller  quantities.  In  many  in- 
stances characteristic  paralyses  follow.  A  fatal  dose  of 
poison  is  contained  in  a  small  fraction  of  a  drop  of  the 
culture  fluid.  Injected  under  the  skin,  it  produces  in- 
flammatory swelling  and  even  necrosis.  But  the  charac- 
teristic diphtheritic  inflammation  is  not  produced  by  any 
soluble  poison.  By  the  repeated  injection,  at  intervals,  of 
non-fatal  doses  of  diphtheria  toxin  animals  become  immu- 
nized to  enormous  quantities  of  poison,  and  are  likewise 
rendered  germ-proof  thereby.  The  immune  animal  has 
developed  a  remarkable  new  property  in  its  blood-serum. 
The  immune  serum  is  an  antidote  against  the  diphtheria 
poison,  and  the  intensity  of  this  antidotal  action  is  pro- 
portionate to  the  degree  of  immunity.  The  quantity  of 
antidote  which  will  neutralize  an  amount  of  poison  repre- 
senting a  ten-fold  fatal  dose  for  a  guinea-pig  is  termed 
an  antitoxin  unit.  By  suitable  immunization  of  horses 
during  the  course  of  a  number  of  months  a  serum  can  be 
obtained  containing  as  an  extreme  about  500  units  per 
cubic  centimeter.     The  neutralization  of  diphtheria  toxin 


CONTAGIOUSNESS.  28/ 

by  immune  serum  takes  place  if  the  two  are  mixed  before 
injection,  or  if  either  be  injected  a  short  time  before  the 
other.  But  if  many  hours  are  allowed  to  elapse  between 
the  injection  of  the  poison  and  its  antidote,  the  requisite 
number  of  antidotal  units  must  be  enormously  increased. 
The  longer  the  animal  has  been  under  the  influence  of 
the  poison,  the  more  antitoxin  does  it  take  to  undo  the 
effect  of  the  poison,  until  the  recovery  of  the  animal 
becomes  at  last  impossible.  Antitoxic  serum  has  no 
direct  effect  upon  the  diphtheria  bacillus.  It  does  not 
influence  its  life  in  any  way.  But  by  protecting  the 
organism  against  the  deleterious  effects  of  the  poisons 
which  this  germ  generates,  it  enables  the  system  to  treat 
the  diphtheria  bacillus  as  a  harmless  parasite.  The  ani- 
mal organism  has  the  ability  to  rid  itself  of  all  microbic 
parasites  which  do  not  overwhelm  the  resisting  power  of 
the  system. 

199.  Diphtheria,  as  seen  clinically,  is  usually  a  mixed 
infection,  or  at  least  becomes  so  in  the  course  of  the  dis- 
ease. Streptococci  or  staphylococci,  or  both,  as  well  as 
various  other  forms  of  microbes,  are  found  to  a  variable 
extent  associated  with  the  diphtheria  bacillus  and  often 
replace  it  later  on.  The  gravity  of  the  disease  is  ap- 
parently much  enhanced  by  this  mixed  infection,  which 
is  more  pronounced  the  more  severe  or  septic  the  form  of 
the  disease.  On  the  other  hand,  the  diphtheria  invasion 
may  be  secondary  to  some  prior  lesion  of  mucous  mem- 
branes. Thus  we  may  have  a  secondary  diphtheria  as  a 
sequel  to  the  sore  throat  of  scarlet  fever,  measles,  or 
syphilis.  When  ulcerations  due  to  any  other  affection 
become  diphtheritic  in  appearance,  the  diphtheria  bacil- 
lus is,  as  a  rule,  found  to  be  the  cause.  A  diphtheritic 
appearance,  however,  may  also  be  due  to  streptococcic 
infection. 

200.  Diphtheria  is  eminentl}^  contagious.  Coughing, 
spitting,  and  even  speaking  disseminate  through  the  air 
microscopic  droplets  of  fluid  containing  the  living  germs. 
Physical  considerations  make  it  likely  that  this  mode  of 


266  DIPHTHERIA. 

infection  can  spread  only  through  a  small  area.  There 
is  more  danger  from  kissing  and  the  handling  of  toys  and 
soiled  utensils.  Sputum  dried  on  the  handkerchief  may 
scatter  the  germs  as  dust.  According  to  clinical  expe- 
rience the  dissemination  of  the  germ  through  attendants 
and  clothing  does  not  occur  to  any  great  extent,  and  the 
greatest  danger  is  from  direct  contact.  It  has  often  been 
claimed,  but  never  absolutely  proven,  that  the  virus  may 
be  disseminated  through  milk.  The  danger  of  the  diph- 
theria patient  to  others  persists  for  at  least  a  number  of 
weeks,  sometimes  over  two  months,  after  perfect  recov- 
ery; for  during  this  period  of  time  living  virulent  germs 
can  be  detected  in  the  throat  and  often,  too,  in  the  nose. 

The  disease  is  most  likely  to  become  epidemic  during 
the  cold  season  and  in  crowded  localities,  evidently  on 
account  of  the  greater  facilities  for  its  dissemination.  Its 
incubation  is  two  to  three  days,  but  as  infection  does  not 
necessarily  follow  at  once  upon  introduction  of  the  germ 
into  the  mouth,  a  week  or  even  more  may  elapse  before 
the  disease  breaks  out  after  exposure. 

20I.  Since  the  treatment  of  diphtheria  is  absolutely 
specific,  the  diagnosis  should  be  established  by  bacterio- 
logic  test.  But  it  would  not  be  wise  to  wait  half  a  day  or 
longer  until  the  test  has  been  made  or  reported  upon  by 
some  expert.  Time  is  of  the  utmost  importance  in  the 
use  of  antitoxin.  It  should,  therefore,  be  injected  at  once 
upon  clinical  indications,  and  deferred  only  until  the  end 
of  the  bacteriologic  test  in  cases  when  the  clinical  diag- 
nosis is  in  doubt.  The  best  results  are  obtained  by  in- 
jecting at  once  a  large  number  of  units — not  less  than  3000, 
and  4000  or  more  whenever  the  symptoms  are  pronounced 
or  the  case  has  advanced  beyond  the  first  half  day.  When 
extension  threatens,  the  dose  may  be  repeated  several 
times  if  needed,  at  intervals  of  twelve  hours.  As  a  rule, 
this  is  not  necessary.  The  hypodermic  injection  should 
be  made  with  full  aseptic  precautions  to  guard  against 
the  possibility  of  abscesses.     The  antitoxic  serum  itself 


TREATMENT.  289 

is  put  up  sterile  and  usually  preserved  by  the  addition  of 
trikresol  (0.5  per  cent). 

As  the  result  of  this  treatment  the  fever  disappears  in 
from  one  to  three  times  twenty-four  hours,  but  the  symp- 
toms of  systemic  disturbance  cease  sooner,  so  that  the 
child,  hitherto  sick,  begins  to  play.  There  is  no  apparent 
influence  upon  the  membrane,  but  almost  invariably  fur- 
ther extension  of  the  diphtheritic  inflammation  ceases 
at  once.  When  the  larynx  is  still  intact  at  the  time  of 
injection,  croup — formerly  so  much  dreaded — scarcely 
ever  appears.  There  is,  accordingly,  too,  but  little  to 
fear  of  other  sequels  like  bronchopneumonia. 

It  is  difficult  to  state  in  an  individual  case  that  the 
recovery  is  due  to  the  treatment,  as  the  disease  in  favor- 
able cases  heals  spontaneously  in  the  same  way.  But  the 
influence  of  the  specific  treatment  upon  the  mortality  is 
now  universally  admitted.  The  few  voices  raised  against 
antitoxin  on  the  part  of  writers  not  open  to  conviction 
have  now  practically  ceased.  Statistics  from  the  entire 
civilized  world  have  shown  that  the  mortality  has,  on  an 
average,  been  at  least  cut  in  two,  while  individual  ob- 
servations under  favorable  circumstances  with  sufficiently 
large  dosage  and  early  employment  of  antitoxin  have 
3aelded  results  even  much  more  favorable.  The  crucial 
test,  indicating  the  value  of  the  specific  treatment  of 
diphtheria,  is  the  mortality-rate  arranged  according  to 
the  date  of  employment  of  antitoxin.  Within  the  first 
twenty-four  hours  the  death-rate  has  been  below  5  per 
cent.,  and  in  many  small  series  has  been  nearly  zero. 
When  employed  after  the  first  day,  the  antitoxin  has  less 
decisive  control  over  the  disease  until  the  influence  is 
nearly  lost,  apparently,  by  delaying  the  injection  until 
the  fourth  or  fifth  day  of  the  disease.  No  other  treat- 
ment in  this  or  any  other  disease  has  been  tested  in  this 
crucial  manner  in  so  many  thousands  of  instances  and 
with  such  incontrovertible  results.  Even  though  sta- 
tistics do  not  show  a  reduction  of  the  death-rate  when 
the  treatment  is  delayed  until  the  fifth  day,  it  must  not 

19 


290  DIPHTHERIA. 

be  forgotten  that  these  delayed  and  hence  selected  cases 
represent  a  series  of  more  than  average  severity,  and  hence 
ordinarily  of  more  than  average  mortality.  For  other- 
wise there  wonld  be  no  need  of  beginning  the  injections 
at  this  late  time.  Deaths  occurring  w^ithin  twelve  hours 
after  the  injection  simply  show  that  the  treatment  was 
begun  too  late  and  had  not  had  time  to  exert  its  effect. 

202.  There  are  no  contraindications  against  the  use  of 
antitoxin.  In  about  10  per  cent,  of  cases  the  injection 
gives  rise  to  disagreeable,  but  not  serious,  consequences. 
Within  one  or  a  few  days  it  may  be  followed  by  a  rash 
resembling  either  measles  or  scarlet  fever,  but  lasting 
only  a  day  or  two,  with  moderate  fever,  occasionally 
nettle-rash,  and  in  rare  instances  inflammatory  swelling 
around  some  joints,  which  subsides  within  a  few  days. 
The  few  deaths  which  have  occurred  shortly  after  in- 
jections were  due  partly  to  the  severity  of  the  disease, 
partly  to  other  sometimes  unaccountable  influences,  like 
habitus  lymphaticus.  It  is  well  known  that  any  trivial 
operation  may  sometimes  be  followed  by  immediate  un- 
accountable death.  Very  few  minor  operations  have  been 
practised  on  so  enormous  a  scale  as  antitoxin  injections. 

203.  It  is  very  questionable  whether  we  possess  any 
means  of  treatment  to  influence  diphtheria  except  anti- 
toxic serum.  A  comparison  of  the  enormous  array  of 
drugs  recommended  formerly  by  every  writer,  with 
strong  individual  preferences  not  shared  by  any  other 
writer,  leaves  but  little  doubt  that  the  treatment  was 
more  suggested  by  humane  intentions  than  by  positive 
knowledge.  None  of  the  means  of  local  applications 
have  ever  been  tested  statistically  according  to  the  day 
of  their  employment.  They  are  all  being  gradually  dis- 
carded. Loffler,  the  discoverer  of  the  diphtheria  bacillus, 
tested  the  ability  of  antiseptics  to  kill  the  bacillus  im- 
mediately and  to  penetrate  at  the  same  time  through 
thick  layers  of  a  culture.  His  most  satisfactory  results 
were  obtained  with  a  fluid  known  as  the  Lofiier  mix- 
ture— viz. : 


-TREATMENT.  29 1 

Toluol 10 

Menthol 2 

Tincture  of  chlorid  of  iron 4 

Alcohol up  to  100. 

This  has  been  tried  on  a  limited  scale  for  the  local  treat- 
ment of  diphtheria,  and  while  moderately  praised,  has 
not  found  universal  recognition.  It  undoubtedly  does 
penetrate  deeply,  killing  both  the  diphtheria  bacillus  as 
well  as  other  germs  present  as  far  as  it  reaches.  But, 
after  all,  those  in  the  depth  of  the  false  membranes  escape 
largely.  Yet,  judged  by  clinical  evidence  in  individual 
cases,  its  use,  when  brushed  upon  the  affected  spots  once 
in  four  to  eight  hours,  is  not  without  some  benefit.  It 
certainly  has  a  very  decided  and  lasting  effect  upon  the 
foulness  of  the  breath.  The  offensiveness  of  the  breath 
is  also  controlled  to  some  extent  by  mouth-washes  and 
gargles  of  the  less  irritating  antiseptics  and  aromatics, 
as,  for  instance — 

Thymol 2 

Oil  of  cloves I 

Oil  of  cassia 0.5 

Chloroform 5 

Alcohol 25 

of  which  one  teaspoonful  is  dissolved  in  a  glass  of  water 
(8  oz.). 

The  constitutional  treatment  of  diphtheria  and  the 
methods  of  quarantine  and  disinfection  can  be  found  in 
all  text-books  on  general  medicine.  The  indications  and 
surgery  of  intubation  and  tracheotomy  are  likewise  out- 
side of  the  scope  of  the  present  work. 

204.  Individuals  exposed  to  the  disease  are  protected 
against  it  almost  infallibly  by  a  prophylactic  injection  of 
at  least  150  units  of  antitoxin,  if  given  within  twenty- 
four  hours  after  exposure.  Two  or  three  days  after  ex- 
posure a  larger  dose  (600  units)  is  required,  and  even  this 
may  not  protect  absolutely,  but  infallibly  reduces  the  dis- 
ease to  a  very  mild  type.     The  passive  immunity  pro- 


292  DIPHTHERIA. 

duced  by  antitoxin  injection  lasts  a  number  of  weeks, 
not  exceeding  about  six. 

205.  A  singular  and  exceptional  form  of  chronic  disease  appa- 
rently due  to  the  diphtheria  bacillus  has  recently  been  reported 
(Neisser  and  Kahnert).  Five  instances  were  observed,  all  in 
young  women.  For  years  they  had  complained  of  dryness  in  the 
throat,  discomfort,  even  some  pain,  and  viscid  secretion,  but  prac- 
tically only  during  the  cold  season,  with  apparent  intermission 
during  summer.  Purulent  crusts  without  fetor  were  found  in  the 
nose  and  entire  pharj^nx  down  to  the  larynx.  The  mucous  mem- 
brane appeared  atrophic,  somewhat  vulnerable,  partially  con- 
gested. The  symptoms  resembled  those  of  non-fetid  atrophic 
rhinitis,  but  with  extension  through  the  pharynx.  The  only 
micro-organism  found  absolutely  constant  was  the  typical  genuine 
diphtheria  bacillus,  but  devoid  of  pathogenic  propertj^  in  some  of 
the  cases.  In  one  instance  only  the  disease  dated  from  a  former 
attack  of  diphtheria.  The  serum  of  several  patients  had  antitoxic 
efficiency.    Injections  of  antitoxin  did  not  influence  the  disease. 


CHAPTER  XXV. 

SYPHILIS   OF    THE   NOSE  AND   PHARYNX TUBER- 
CULOSIS.—SCROFULA LEPROSY 

RHINOSCLEROMA. 

SYPHILIS  OF  THE  UPPER  AIR-PASSAQES. 

ao6.  In  the  course  of  syphilis  the  pharynx  is  involved, 
as  a  rule,  during  the  early  period  of  secondary  manifesta- 
tions. But  this  form  of  lesion  is  not  often  seen  by  the 
rhinologist  Yet  syphilitic  manifestations  in  general  are 
so  common  in  the  nose  and  throat  that  they  constitute  at 
least  2  per  cent,  of  average  practice  in  this  field. 

The  primary  sore,  very  exceptionally  found  in  the 
nasal  vestibule  or  near  the  front  end  of  the  septum,  is 
not  so  rare  in  the  mouth  and  pharynx.  In  statistics  of 
over  10,000  cases  of  extragenital  chancres  compiled  by 
Bulkley,  and  continued  by  Miinchheimer,  .5  per  cent, 
were  observed  in  the  tonsils  and  nearly  3  per  cent,  in 
other  parts  of  the  pharynx.  The  infection  was  conveyed 
partly  by  lascivious  modes  of  kissing  and  sexual  aberra- 
tion, partly  by  utensils  and  tools — for  instance,  the  blow- 
pipe of  glass-workers.  More  than  50  pharyngeal  chancres 
have  been  reported  from  the  use  of  infected  Eustachian 
catheters.  Infants  acquire  the  disease  by  nursing.  The 
sore  appears  as  a  sharply  cut  ulcer  with  unclean  surface, 
surrounded  by  an  edematous  and  reddened  areola,  of 
indolent  course,  lasting  weeks,  even  up  to  two  months. 
Usually  but  not  always  the  base  becomes  indurated.  Adja- 
cent lymph-glands  become  inflamed  and  palpable.  The 
diagnosis  cannot  be  made  absolute  unless  the  history  of 
exposure  is  certain,  or  until  secondary  symptoms  appear. 
Yet  the  only  ulcers  for  which  it  might  be  mistaken — 
after  an  existence  of  two  weeks  or  more — are  secondary 

293 


294  SYPHILIS    OF   THE    NOSE   AND    PHARYNX. 

syphilitic   ulceration,   tubercular   ulcers,   and  ulcerating 
carcinoma. 

Until  the  diagnosis  is  beyond  the  possibility  of  doubt 
^  it  is  not  to  the  interest  of  the  patient  to  use  specific 
medication.  If  a  sore  disappears  under  specific  treatment 
before  its  nature  is  certain,  the  diagnosis  of  syphilis  may 
be  left  in  uncertainty  for  months  and  years.  The  ulcer 
heals  in  the  end  without  treatment,  but  its  cure  can  be 
hastened  by  nitrate  of  silver,  tincture  of  iodin,  or 
Loffler's  solution,  and  its  discomfort  lessened  by  ortho- 
form  insufiiations. 

207.  During  the  early  secondary  stage  the  throat,  as  a 
rule,  is  affected  by  syphilis.  But  as  these  lesions  are  rela- 
tively mild  and  their  cause  is  usually  known  to  the  patient, 
they  are  but  seldom  seen  in  special  rhinologic  practice. 
Syphilitic  er^'thema,  common  on  the  palate,  less  so  on 
the  posterior  pharyngeal  wall,  appears  in  the  form  of  red, 
well-circumscribed  spots,  often  symmetric.  It  causes 
slight  soreness  and  is  transient.  It  may  persist,  however, 
as  a  deeper  type  of  inflammation  in  the  form  of  a  tonsil- 
litis, presenting  sometimes  the  typical  appearance  of 
follicular  tonsillitis.  Whenever  this  lasts  more  than 
about  a  week,  with  steady  but  moderate  soreness  and 
without  acute  onset,  it  can  be  safely  referred  to  syphilis. 

Mucous  patches  are  among  the  most  frequent  and  per- 
sistent of  the  early  syphilitic  manifestations,  with  dis- 
tressing liability  to  recurrence.  They  occur  anywhere 
in  the  mouth — on  the  tongue,  or  at  its  base,  along  the 
pillars,  on  the  tonsils,  or  less  commonly  the  posterior 
wall  of  the  pharynx.  At  first  resembling  spots  produced 
by  cauterization  with  nitrate  of  silver,  they  are  oval  or 
irregular,  slightly  raised,  grayish-white  patches  of  varia- 
ble size,  surrounded  by  a  slightly  reddened  areola,  the 
color  of  which  is  most  saturated  (by  contrast)  at  the 
edge  of  the  gray  patch.  In  mild  or  well-treated  instances 
they  may  disappear  in  the  course  of  one  to  two  weeks. 
But,  as  a  rule,  they  undergo  further  changes.  The  epi- 
thelium becomes  macerated  and  gradually  detached,  and 


SVi.4:US    OF   THE    UPPER    AIR-PASSAGES.  295 

a  slightly  bleeding  sore  surface  remains.  This  may  pro- 
ceed to  deeper  ulceration  if  not  treated,  especially  on  the 
tonsils.  By  the  coalescence  of  several  elliptic  ulcers  a 
characteristic  "serpiginous"  appearance  is  often  pro- 
duced. The  ulcers  may  become  complicated  by  second- 
ary infection,  mainly  with  streptococci,  but  even  occa- 
sionally with  the  diphtheria  bacillus. 

In  the  nose  early  secondary  manifestations  are  said  to 
be  rare  or  at  least  give  rise  to  so  little  disturbance  that 
they  are  not  recognized.  The  writer,  however,  has  a  few 
times  seen  very  persistent  superficial  ulcerations  on  the 
septum,  serpiginous  in  appearance,  but  without  tendency 
to  extend  in  depth.  They  were  probably  the  outcome  of 
mucous  patches,  and  when  recognized  after  a  duration  of 
months,  yielded  quite  promptly  to  specific  treatment. 

208.  The  later  or  so-called  tertiary  forms  of  syphilitic 
localization  in  the  nose  and  throat  are  not  rare.  They 
may  appear  within  one  year  after  infection,  but  are  much 
more  common  at  later  periods,  even  twenty  years  or  more 
after  the  beginning  of  the  disease.  In  the  pharynx  the 
lesion  is  a  gummatous  infiltration.  It  is  either  relatively 
diffuse  and  superficial,  being  in  the  mucous  membrane 
itself,  or  it  may  be  a  more  circumscribed  nodule  in  the 
underlying  tissues.  Its  preferred  site  is  the  soft  palate, 
less  often  the  pillars,  but  it  may  occur  on  the  posterior 
wall  or  the  lingual  tonsil,  or  be  hidden  in  the  naso- 
pharyngeal space.  It  causes  but  little  disturbance  until 
it  ulcerates,  which  happens  in  the  course  of  one  to  two 
weeks,  unless  energetically  treated  from  the  start.  When 
the  gumma  breaks  down,  a  small,  well-defined,  often 
crater-shaped  opening  is  found,  from  which  a  thin  puru- 
lent secretion  issues.  If  healing  is  not  brought  about 
by  prompt  treatment,  further  extension  of  ulceration  fol- 
lows, probably  dependent  on  secondary  infection  with 
other  microbes.  In  the  soft  palate  a  gumma  usually 
opens  on  both  surfaces,  and  causes  thus  a  permanent  per- 
foration. If  situated  on  the  posterior  wall  or  the  pillars, 
the  ulceration  is  likely  to  lead  to  extensive  shrinkage  and 


296  SYPHILIS    OF   THE    NOSE   AND    PHARYNX. 

adhesions  after  healing.  Very  serious  mechanical  dis- 
turbances may  result  therefrom.  In  some  instances  gum- 
matous ulceration  of  the  throat  has  given  rise  to  serious, 
even  fatal,  hemorrhages.  In  the  nasopharynx  syphilitic 
ulceration  causes  severe  headache  and  profuse  secretion. 
Postnasal  examination  with  the  mirror  should  not  be 
neglected  in  syphilitic  patients  with  symptoms  of  disease 
above  the  palate. 

Within  the  nose,  syphilis  can  produce  a  number  of 
well-defined  lesions  which  can  be  distinguished  as — 

Gummatous  infiltration. 

Ulceration  of  the  septum. 

Necrosis  of  bony  wall. 

Diffuse  hypertrophic  rhinitis. 

Syphilomatous  tumors. 

Ultimate  atrophy  of  the  mucous  membrane. 

209.  Gummatous  infiltration  appears  as  a  more  or  less 
circumscribed  tumefaction  mostly  on  the  septum,  in  its 
upper  and  anterior  area,  to  a  less  extent  along  the  floor  or 
on  the  inferior  turbinal.  In  other  localities  it  is  quite 
uncommon.  During  the  formation  of  the  gumma  it 
may  cause  considerable  aching  pain  or  headache,  espe- 
cially if  on  the  septum.  Otherwise  no  symptoms  are 
produced  except  slight  stuffiness,  but  breaking  down  of 
the  gumma  is  sure  to  follow  unless  it  is  promptly  treated. 
A  crater-shaped  fistula  results,  leading  into  considerable 
depth.  The  purulent  secretion  issuing  is  likely  to  dry  in 
the  form  of  crusts.  From  this  time  on  there  may  or  may 
not  be  associated  with  the  localized  gumma  a  diffuse 
rhinitis  with  profuse  discharge  of  pus.  The  ulceration 
of  the  gumma  shows  no  tendency  to  extend  in  area 
except  when  situated  on  the  septum. 

210.  Late  syphilis  leads  often  to  characteristic  perfora- 
tion and  destruction  of  the  septum.  It  is  not  definitely 
known  whether  this  ulceration  always  starts  from  a  dis- 
tinctly localized  gumma  or  not.  It  begins  usually  in  the 
cartilaginous  portion,  often  but  not  always  quite  high  up, 


SYPHILIS    OF   THE    UPPER    AIR-PASSAGES.  29/ 

but  is  sure  to  extend  to  the  bony  septum  unless  checked. 
It  is  a  typical  progressive  caries.  If  not  checked,  it  will 
destroy  a  large  part  of  the  septum  in  the  course  of  months 
or  years.  The  perforation  is  rarely  seen  when  very  small, 
as  probably  a  fairly  large  area  sloughs  away  at  once.  It 
has  not  the  typical  round  form  of  the  non-syphilitic 
perforating  ulcer.  Its  edges  are  thickened  and  often  de- 
formed. The  ulcerated  edge  secretes  a  thick  pus,  which 
dries  in  adherent,  yellowish-green  crusts.  Quite  com- 
monly there  is,  besides,  free  purulent  secretion  from  the 
entire  nasal  surface.      (Compare  Fig.  2,  Plate  I.) 

In  the  course  of  time  caries  of  tiie  septum  is  followed 
by  deformity  of  the  external  nose,  sometimes  with  pitiful 
disfiguration.  Of  course,  all  possible  degrees  of  deformity 
may  be  seen,  from  slight  sinking  in  of  the  bridge  to  a 
typical  saddle-shaped  nose,  or  a  retraction  of  the  entire 
external  organ,  leaving  two  up-turned  apertures.  Even 
these  may  be  disfigured  or  narrowed  if  gummatous  infil- 
tration of  the  alse  nasi  has  been  allowed  to  do  its  ravages 
without  check.  The  sinking  in  of  the  nose  is  not  due  to 
the  mere  defect  of  the  septum.  Even  a  very  large  per- 
foration leaves  the  septum  strong  enough  to  support  the 
bridge.  Indeed,  the  latter  is  practically  self-supported 
by  the  architecture  of  the  nasal  bones.  Moreover,  the 
sinking  in  does  not  occur  during  the  time  the  perforation 
extends,  but  usually  follows  it  at  a  later  period.  The  re- 
traction is  due  to  cicatricial  shrinkage  of  the  septum,  and 
is  rarely  seen  in  patients  who  have  been  properly  treated, 
even  though  they  have  a  large  hole  in  the  septum. 

211.  Essentially  different  from  the  caries  of  the  septum 
is  syphilitic  necrosis  of  the  bony  walls.  This  is  not  a 
progressive  lesion.  It  is  practically  never  seen  at  its 
beginning  when  the  patient  merely  complains  of  some 
stuffiness.  It  probably  begins  as  a  syphilitic  disease  of 
the  arteries  of  a  small  area,  leading  to  their  obliteration 
and  to  the  death  of  a  circumscribed  sequestrum  of  bone. 
The  piece  of  dead  bone  varies  in  size  as  much  as  ordinary 
coins  do.     It  is  more  often  a  fragment  of  two  adjoining 


398  SYPHILIS    OF   THE    NOSE   AND    PHARYNX. 

walls  than  a  single  plane  lamella  of  bone.  Its  most  fre- 
quent location  is  at  the  rear  area  of  the  junction  of  the 
horizontal  plate  of  the  palate  bone  and  the  vomer,  but  it 
may  occur  almost  anywhere.  Perforations  of  the  hard 
palate  with  opening  between  mouth  and  nose  are  com- 
mon and  characteristic.  As  a  rule,  they  are  small  on 
account  of  the  integrity  of  the  lining  membrane  of  the 
mouth.  The  maxillary  sinus  may  be  opened  by  necrosis. 
A  portion  of  the  ethmoid  labyrinth  may  come  away. 
In  one  case  on  record  the  sphenoid  body  was  thrown  off. 
The  symptoms  which  compel  the  patient  to  seek  advice 
are  the  oflfensive  discharge  and  the  horrible  stench.  The 
latter  is  absolutely  characteristic  of  syphilitic  necrosis.  It 
cannot  be  influenced  in  any  way  whatsoever  until  the  piece 
of  dead  bone  is  removed.  No  matter  how  accessible  the 
sequestrum  may  seem,  deodorizing  substances  will  not 
conquer  the  smell.  By  the  use  of  douches  with  perman- 
ganate of  potassium  and  sprays  of  essential  oils  the  patient 
can  merely  make  his  presence  tolerated  until  the  dead 
bone  is  removed.  The  sequestrum  can  be  felt  by  the 
probe.  On  account  of  the  intricate  anatomy  of  the  nose 
it  would  usually  require  a  formidable  operation  to  remove 
the  sequestrum.  It  is  hence  the  wiser  plan  to  wait  until 
it  is  nearly  detached,  when  it  can  be  seized  with  forceps 
and  extracted.  This  may  take  from  three  to  six  weeks 
or  even  longer.  By  breaking  off  a  portion  of  the  seques- 
trum and  leaving  a  part  in  place,  nothing  is  gained. 
Within  a  few  days  after  the  dead  bone  is  cast  off  the  odor 
ceases.  The  necrosis  is  not  progressive,  and  hence  as 
such  is  not  influenced  by  specific  treatment.  But  it  is 
commonly  associated  with  a  purulent  rhinitis,  which  is 
of  specific  origin  and  which  yields  to  internal  medication 
as  soon  as  the  necrotic  .piece  of  bone  has  been  expelled. 

212.  In  connection  with  the  various  lesions  described 
there  is,  as  a  rule,  a  diffuse  purulent  rhinitis  with  moder- 
ate diffuse  swelling  of  the  nasal  mucous  membrane.  This 
form  of  syphilitic  rhinitis  is  characterized  by  a  profuse, 
thick,  greenish-yellow  discharge  tending  to  dry  in  the 


SYPHILIS    OF   THE   UPPER    AIR-PASSAGES.  299 

form  of  adherent  crusts.  If  there  is  no  bony  necrosis,  no 
odor  is  present  at  first.  But  by  reason  of  neglect  second- 
ary decomposition  may  take  place  and  give  rise  to  a  foul 
smell.  Characteristic  of  the  disease  is  its  tendency  to 
form  broad  adhesions.  Synechise,  especially  when  multi- 
ple, between  the  septum  and  the  turbinal  processes  are 
almost  diagnostic  of  syphilis,  unless  clearly  due  to  im- 
properly done  operations  or  cauterization.  This  purulent 
rhinitis,  unlike  most  syphilitic  lesions,  is  not  self-limited 
if  not  specifically  treated.  During  its  earlier  period  it 
yields  to  internal  medication,  aided  by  local  measures, 
though  not  always  promptly.  If  it  has  been  allowed  to 
turn  into  atrojjhy  of  the  mucous  membrane,  it  is  almost 
incurable. 

213.  A  special  form  of  localized  nasal  hypertrophy  of 
syphilitic  origin  is  the  syphiloma,  a  tumor  of  granulation 
tissue.  The  tumor,  sometimes  multiple  and  variable  in 
size,  is  soft  and  friable  and  easily  broken  down  by  manipu- 
lation. In  color  it  is  grayish  pink.  It  may  spring  from 
the  septum  or  from  a  turbinal.  It  is  often,  but  not  always, 
associated  with  gummatous  infiltration  or  some  destruc- 
tive process  adjacent  to  it.  Besides  local  stuffiness  and 
discharge,  it  may  give  rise  to  distant  symptoms  like 
headache.  It  is  a  rare  lesion,  and  may  create  diffi- 
culty in  diagnosis.  Histologically,  it  cannot  be  readily 
distinguished  from  tubercular  tumors  and  soft  sarcomata. 
It  consists  of  mucous  membrane  infiltrated  with  round 
cells,  so  as  to  give  it  the  structure  of  granulation  tissue, 
often  containing  some  giant  cells.  Its  arteries  are  char- 
acteristically thickened  by  round-cell  infiltration.  The 
best  plan  is  to  remove  it  at  once  by  the  use  of  the  snare. 
A  relapse,  however,  must  be  expected  unless  specific 
treatment  is  pursued. 

314.  When  syphilitic  rhinitis  is  not  checked  in  the 
beginning  by  specific  treatment,  it  proceeds  to  the  stage 
of  atrophy  of  the  entire  nasal  mucous  membrane.  The 
clinical  appearance  is  now  strikingly  like  that  of  ad- 
vanced ozena — viz.,  large  spacious   passages  with  rudi- 


300 


SYPHILIS    OF    THE    NOSE   AND    PHARYNX. 


mentary  appearance  or  nearly  complete  absence  of  the 
turbinals,  and  thin,  dry,  cicatricial  looking  mucous  mem- 
brane lined  with  adherent  greenish  crusts  (Fig.  84).  The 
presence  of  any  ulceration  or  perforation  of  the  septum 
distinguishes   it    absolutely   from    non-syphilitic   ozena. 


Fig.  84. — Syphilis  of  the  nose  ;  external  nose  sunken  in ;  alveolar  process 
defective,  and  communication  between  nose  and  mouth ;  septum  almost  entirely 
destroyed,  except  at  its  rear  end.  The  alse  nasi  are  enormously  thickened,  and 
the  mucous  membrane  is  mostly  hypertrophic.  Inferior  turbinal  atrophied,  espe- 
cially in  front ;  middle  turbinal  atrophied  in  front,  enlarged  toward  the  rear ; 
hiatus  semilunaris  exposed  by  reason  of  atrophy  of  its  bony  boundaries  while 
the  surrounding  mucous  membrane  is  considerably  hypertrophied  (Zuckerkandl). 


The  odor,  too,  is  not  quite  that  of  ozena,  though  it  may 
resemble  it  closely.  In  some  instances  there  is  no  odor. 
At  this  stage  the  disea.se  is  practically  incurable.  The 
annoyance  may  be  lessened  by  the  continued  use  of 
douches  and  Gottstein's  tampons.  Specific  treatment 
has  no  influence  upon  it. 


TREATMENT.  3OI 

315.  All  specific  lesions  in  the  nose  and  throat  are 
very  readily  controlled  by  internal  treatment  if  begun 
early.  The  earlier  or  secondary  manifestations  require 
mercury.  Its  effect  is  the  same  whether  given  internally, 
by  hypodermic  injection,  or  by  inunction.  The  latter 
mode  is  regarded  as  the  most  thorough  and  permanent 
in  its  effects.  It  is  not  necessary,  and,  indeed,  very  un- 
desirable, to  induce  salivation  or  disease  of  the  gums. 
This  should  be  guarded  against  by  thorough  attention  to 
the  teeth  by  removing  tartar  and  by  mechanical  cleansing. 
Thorough  dental  cleanliness  should  be  enforced.  The 
gums  may  be  hardened  by  using  finely  powdered  salt 
upon  the  tooth-brush.  Care  must  be  taken  not  to  per- 
mit the  presence  of  decomposing  food  between  the 
teeth,  and  any  cavities  should  receive  the  attention  of  a 
dentist.  The  slightest  salivation  or  tenderness  or  bleed- 
ing of  the  gums  should  cause  a  temporary  intermission 
in  treatment.  If  the  gums  become  affected,  they  may 
be  brushed  with  diluted  tincture  of  myrrh  (i :  20),  and 
a  mouth-wash  of  thymol  solution  and  oil  of  cloves  (Tf  134) 
may  be  used  at  short  intervals.  Chlorate  of  potash  tab- 
lets kept  between  gums  and  cheek  seem  also  to  be  of 
some  service. 

lodid  of  potassium  has  a  less  pronounced  influence  on 
the  early  specific  lesions,  unless  they  assume  a  gummatous 
appearance  independent  of  their  recent  date.  In  later 
manifestations  iodid  is  the  sovereign  remedy.  Its  dosage 
must  be  increased  rapidly  until  an  effect  is  obtained, 
which  should  be  apparent  in  four  or  five  days.  It  is  best 
to  begin  with  15  drops  of  the  saturated  solution  in  order 
to  guard  against  unpleasant  effects,  which  may  exception- 
ally occur  in  case  of  idiosyncrasy.  The  dose  should  be 
increased  by  5  drops  each  successive  time  (three  times 
daily)  until  an  effect  is  obtained  or  up  to  the  limit  of 
tolerance.  In  exceptional  cases  as  much  as  8  to  10  grams 
per  dose  may  be  required — usually  one-third  of  this  suf- 
fices. It  is  tolerated  best  when  given  after  meals  in 
several  glasses  of  fluid,  preferably  milk.     A  slight  degree 


302  SYPHILIS    OF   THE    NOSE   AND    PHARYNX. 

of  iodism  need  not  interrupt  its  administration,  as  these 
untoward  symptoms  may  disappear  in  spite  of  its  con- 
tinued use. 

Local  treatment  is  often  required  in  addition  on  account 
of  the  complication  by  secondary  infections.  Ulcerated 
surfaces  are  benefited  by  nitrate  of  silver  application  (20 
to  30  per  cent.)  or  Loffler's  solution.  The  pain  of  ulcers 
in  the  pharynx  is  alleviated  by  orthoform.  Nasal  sup- 
puration requires  removal  of  discharge  by  the  douche  or 
at  least  the  frequent  cleansing  with  liberally  used  sprays. 
When  the  nasal  secretion  dries  in  the  form  of  crusts  in 
spite  of  these  measures,  this  occurrence  can  be  prevented 
by  tampons  of  cotton  or  gauze.  When  applied  to  raw 
surfaces,  iodoform  gauze  for  the  tampon  is  a  distinct  ad- 
vantage, but  not  if  in  contact  with  intact  mucous  mem- 
brane. The  patient  must,  of  course,  be  consulted  whether 
he  will  permit  the  iodoform  odor. 

i?i6.  Inherited  syphilis  can  produce  the  same  lesions  in 
the  nose  and  throat  as  the  acquired  disease.  This  may 
occur  at  any  time  from  earliest  childhood  to  adolescence 
or  beyond.  The  sunken-in  nose  is,  unfortunately,  a  fre- 
quent stigma  of  hereditary  syphilis.  Many  authors  refer 
to  the  frequency  of  diffuse  purulent  rhinitis  (snuffles)  in 
syphilitic  infants.  The  writer  has  not  been  convinced, 
either  by  personal  experience  or  from  any  definite  state- 
ments in  literature,  that  the  often  reiterated  statement 
that  severe  coryza  in  a  nursling  is  strongly  suggestive  or 
even  indicative  of  syphilis  is  based  on  careful  observa- 
tion. Various  syphilitic  lesions,  some  of  them  compli- 
cated with  the  above-described  specific  purulent  rhinitis, 
may  occur  even  at  the  earliest  period  of  life.  But,  on 
the  other  hand,  the  majority  of  instances  of  coryza  in 
syphilitic  infants  are  probably  not  specific  in  origin, 
but  are  merely  acute  nasal  inflammation  complicated 
by  hypertrophy  of  the  pharyngeal  tonsil.  As  soon  as 
the  diagnosis  of  a  nasal  specific  lesion  can  be  made,  the 
infant  should,  of  course,  receive  specific  treatment. 

The  writer  has  not  attempted  to  give  more  than  a  mere 


TUBERCULOSIS;  3O3 

outline  of  the  treatment  of  syphilis,  since  fuller  details 
can  be  found  in  any  special  work  on  syphilis. 


TUBERCULOSIS. 

217.  Tuberculosis  does  not  often  cause  clinical  mani- 
festations in  the  nose  or  pharynx.  In  most  instances  the 
tubercular  lesions  are  secondary  to  other  foci  of  the  dis- 
ease in  the  body.  Yet  occasionally  primary  infection  is 
encountered.  The  disease  begins  as  a  superficial  infiltra- 
tion of  the  mucous  membrane  with  miliary  tubercles 
in  a  small  area.  The  spot  appears  unevenly  swollen  and 
congested  and  is  easily  eroded.  It  changes  soon  into  an 
ulcer  with  ill-defined  edges,  grayish-yellowish  surface, 
and  surrounded  by  flabby,  bleeding  granulations.  Ad- 
joining the  ulcer,  but  sometimes,  too,  without  ulceration, 
the  disease  produces,  in  rare  instances,  tumors  of  granu- 
lation tissue  of  pinkish-gray  appearance  and  spongy  con- 
sistency— tuberculoma,  which  may  puzzle  the  diagnos- 
tician. 

In  the  nose  tubercular  disease  affects  the  septum  more 
frequently  than  other  parts  of  the  wall.  At  the  entrance 
of  the  nose  tuberculosis  of  the  mucous  membrane  is  some- 
times evidently  due  to  extension  of  lupus  of  the  adjacent 
skin.  In  the  pharynx  its  site  by  preference  is  the  soft 
palate.  When  the  uvula  is  involved  in  infiltration,  it  is 
characteristically  changed  into  a  thick,  misshapen  stump. 
When  not  involved,  it  appears  unproportionately  thin. 
Less  often  than  on  the  soft  palate  tuberculosis  may  invade 
other  parts  of  the  postnasal  space  or  pharynx. 

In  the  nose  it  causes  but  moderate  disturbance,  stuffi- 
ness, seropurulent,  fetid  discharge,  not  rarely,  however, 
headache  and  feeling  of  heaviness.  In  the  lower  pharynx 
tubercular  ulceration  causes  great  pain  during  swallow- 
ing, and  if  not  relieved,  may  lead  to  starvation.  It  gives 
a  very  foul  breath,  probably  from  secondary  invasion 
by  concomitant  bacteria.  In  the  nasopharynx  tubercular 
ulceration  may  run  an  almost  latent  course.     Wherever 


304  TUBERCULOSIS    OF    THE    NOSE   AND    PHARYNX. 

situated,  tuberculosis  pursues  a  slow  but  steady  progress 
unless  checked  therapeutically. 

The  diagnosis  is  usually  not  very  difficult.  The  pres- 
ence of  cutaneous  lupus  or  the  appearance  of  yellowish 
miliary  tubercles  at  the  edge  of  the  spot  confirms  the  sus- 
picion raised  by  the  above-described  appearances.  The 
histologic  structure  of  tubercles  in  excised  fragments  or 
the  demonstration  of  the  tubercle  bacillus  renders  the 
diagnosis  absolute.  In  case  of  doubt  certainty  can  be 
obtained  from  a  diagnostic  injection  of  tuberculin. 

2i8.  The  treatment  is  essentially  surgical.  The  tuber- 
cular tumor  is  snared  off.  The  ulcer  is  curetted  and 
cauterized.  Opinions  are  divided  as  to  the  preference  for 
the  galvanocautery  or  the  application  of  lactic  acid  (the 
latter  on  a  pledget  of  cotton).  A  fair  minority  of  per- 
manent cures  have  been  reported.  As  a  rule,  the  disease 
cannot  be  completely  eradicated,  especially  when  com- 
plicated by  tuberculosis  of  other  organs.  The  patient 
should  receive  all  possible  benefits  in  the  way  of  hygienic 
management  and  climatic  environment  that  can  be  given 
him.  Tuberculin  has  received  scarcely  a  fair  trial  in  this 
disease,  as  the  lesions  are  usually  seen  at  an  advanced 
period  beyond  the  power  of  this  specific  agent.  The 
pain  of  pharyngeal  ulceration  can  be  well  controlled  by 
orthoform. 

319.  Much  discussion  has  taken  place  within  the  past 
few  years  as  to  what  extent  the  tubercular  virus  enters 
the  system  through  the  upper  air-passages.  It  was  start- 
ling news  to  learn  that  among  the  healthy  attendants  in 
the  tubercular  wards  of  hospitals  a  large  number  show 
the  presence  of  tubercle  bacilli  on  the  surface  of  the 
intact  nasal  lining.  In  all  probability  the  presence  of 
the  normal  mucus  and  the  movement  of  the  epithelial 
cilia  ordinarily  prevent  infection.  Further  research  has 
shown,  however,  that  tubercles  are  not  uncommon 
in  the  hypertrophied  pharyngeal  and  faucial  tonsil. 
Various  observers  have  found  miliary  tubercles  with 
characteristic   bacilli    in   sections  of  excised   tonsils,  in 


SCROFULOSIS.  305 

some  instances  as  often  as  one  out  of  every  six.  A 
larger  number  of  observations  has  shown  an  average 
of  about  5  per  cent.  This  form  of  tuberculosis  is  en- 
tirely latent,  and  such  tubercular  tonsils  cannot  be 
distinguished  from  ordinary  hypertrophy.  The  signifi- 
cance of  this  frequent  tubercular  infection  is  somewhat 
reduced  by  the  fact  that  it  is  almost  invariably  secondary 
to  tubercular  disease  of  other  organs,  especially  the  lungs. 
It  is,  indeed,  not  proven  that  it  does  ever  occur  as  a  pri- 
mary invasion.  On  the  other  hand,  it  has  been  shown 
that  in  autopsies  of  subjects  dead  of  tuberculosis  tubercles 
are  found  very  commonly  in  faucial  tonsils,  perhaps  a 
little  less  often  in  the  pharyngeal  tonsil.  This  is  true 
even  when  the  tonsil  is  not  morbidlv  enlarged.  Although 
clinically  latent,  tuberculosis  of  the  adenoid  structures  is 
not  harmless,  as  it  leads  to  descending  tuberculosis  of  the 
cervical  lymph-glands  and  may  thus  help  to  disseminate 
the  disease  through  the  body.  The  excision  of  tubercular 
tonsils  causes  no  reaction  different  from  that  in  ordinary 
cases. 

i?20.  Scrofiilosis  has  often  an  important  relation  to 
the  upper  air-passages.  At  present  it  is  almost  generally 
admitted  that  this  disease  is  really  but  a  form  of  tuber- 
culosis, the  reaction  of  the  juvenile  organism  to  poisons 
generated  in  some  tubercular  focus,  usually  in  a  lymph- 
gland.  The  lesions  produced  by  scrofulosis  in  the  nose 
and  pharynx  are  not  in  themselves  tubercular.  The 
most  characteristic  manifestation  is  the  subacute  sero- 
purulent  rhinitis  of  scrofulous  children,  described  in  ^  35. 
A  thin  discharge,  variable  with  the  season,  frequently 
relapsing,  and  often  associated  with  eczema  below  the 
nose,  produces  a  typical  picture.  This  rhinitis  is  the  fre- 
quent precursor  of  phlyctenular  keratitis,  a  character- 
istically scrofulous  affection.  Scrofulous  children  are 
commonly  subject  to  enlargement  of  the  pharyngeal  ton- 
sil in  connection  with  the  rhinitis  described.  There  is, 
as  a  rule,  but  a -minor  degree  of  adenoid  hypertrophy.  It 
is,  however,  rare  to  find  a  scrofulous  child  without  some 
20 


306  LEPROSY. 

adenoid  enlargement.  On  the  other  hand,  it  cannot  be 
said  conversely  that  enlargement  of  the  pharyngeal  tonsil 
is  necessarily  indicative  of  scrofula.  But  some  of  the 
symptoms  formerly  referred  to  scrofula  are  largely  de- 
pendent upon  the  hypertrophy  of  the  tonsil.  The  fre- 
quent attacks  of  nasal  catarrh,  the  thick  lips,  the  liability 
to  purulent  otitis,  all  formerly  considered  manifestations 
of  scrofula,  are  the  direct  results  of  the  pharyngeal  hyper-r 

trophy. 

LEPROSY. 

221.  Although  this  disease  is  but  a  rare  curiosity  in 
our  part  of  the  country,  it  invades  the  upper  air-passages 
so  often  that  a  few  diagnostic  comments  seem  proper.  It 
has  been  claimed  recently  by  Sticker  that  lepra  begins, 
as  a  rule,  in  the  nose  in  the  form  of  septum  ulceration, 
and  that  this  is  one  of  its  most  persistent  manifestations, 
all  the  more  important  because  the  nasal  discharge  con- 
tains the  specific  germs  in  abundance.  The  lesions  in 
the  nose  and  pharynx  consist  of  follicles  which  coalesce 
and  ulcerate.  In  the  course  of  time  a  spontaneous  heal- 
ing takes  place,  resulting  in  smooth  but  extensive  scars, 
sometimes  with  a  good  deal  of  shrinkage.  The  diagnosis 
is  said  to  be  fairly  definite  from  local  appearances,  but 
depends  mainly  on  the  detection  of  the  systemic  disease. 

222.  Rhinoscleroma,  or  scleroma  of  the  upper  air- 
passages,  is  a  disease  which  requires  description  in  con- 
nection with  the  diagnosis  of  syphilitic  and  tubercular 
lesions.  It  is  very  rarely  seen  in  this  country,  and  only 
in  emigrants,  but  is  quite  common  among  the  poor  in 
Poland  and  the  eastern  and  southern  provinces  of  Aus- 
tria. It  is  a  chronic,  slowly  progressive,  incurable  dis- 
ease, which  may  not  destroy  life  iintil  at  a  very  late  period. 
The  lesion  consists  of  nodular  infiltration,  sometimes 
diffuse,  sometimes  circumscribed,  often  multiple.  The 
nodule,  of  hard  and  variable  size,  sometimes  as  large  as  a 
bean,  begins  often  in  the  skin  of  the  external  nose,  and 
may  extend  through  the  upper  lip.  In  other  instances  it 
commences  in  the  pharynx.     Gradually  the  process  ex- 


RHINOSCLEROMA.  307 

tends  throughout  the  entire  air-passages,  including  the 
larynx  and  trachea.  There  is  not  much  ulceration,  but 
rather  a  superficial  erosion,  with  very  profuse  purulent 
discharge,  drying  in  the  form  of  crusts.  The  disease  is 
identical  with  the  blennorrhea  of  the  air-passages  de- 
scribed by  Stoerck.  In  the  course  of  time  the  infil- 
trated mucous  membrane  shrinks,  and  the  resulting  exten- 
sive scars  often  lead  to  narrowing  of  the  pharynx  or 
larynx.  Tracheotomy  may  become  necessary  in  order  to 
prolong  life. 

When  the  diagnosis  cannot  be  made  from  the  appear- 
ance, an  excised  fragment  can  be  examined  microscopi- 
cally. It  shows  granulation  tissue,  with  some  typical 
large  oval  cells.  In  the  tissues  short  bacilli  are  found  in 
great  abundance,  which  resemble  closely  the  pneumo- 
bacillus  of  Friedlander  or  the  bacillus  mucosus  of  ozena. 
They  are  justly  regarded  as  the  cause  of  the  disease. 
Scleroma  cannot  be  influenced  by  any  treatment. 


CHAPTER   XXVI. 

AFFECTIONS    OF    THE    UPPER     AIR-PASSAGES    IN 
THE  COURSE  OF   OTHER   DISEASES. 

223.  Measles. — This  disease  is  characterized  by  con- 
gestion and  irritation  of  the  conjunctiva  and  the  mucous 
membrane  of  the  entire  upper  air-passages  from  the  start 
before  the  cutaneous  eruption  appears.  With  good  illu- 
mination miliary  red  spots  can  often  be  seen  on  the  first 
or  second  day  on  the  nasal  mucous  membrane,  and  still 
more  distinctly  on  the  soft  palate  and  tonsils,  as  well  as 
on  the  inside  of  the  cheek.  The  diagnosis  can  thereby 
be  made  before  the  rash  appears  on  the  skin.  In  the 
milder  cases  the  nasal  and  the  throat  lesions  pass  over 
without  further  complication.  In  cases  of  moderate 
severity  a  secondary  coryza  sets  in,  sometimes  quite  per- 
sistent. Tonsillitis  is  a  relatively  rare  complication,  but 
any  exposure  to  diphtheria  is  ver\'  likely  to  lead  to  in- 
fection as  a  sequel  to  measles.  Nasal  hemorrhages  are 
not  uncommon  before  the  rash  appears.  The  nasal 
sinuses  are  probably  involved  often,  but  it  is  very  rare 
that  their  affection  is  clinically  evident. 

224.  Scarlet  Fever. — It  is  very  rare  and  seems  to 
occur  only  in  the  mildest  cases  that  scarlet  fever  is  not 
ushered  in  by  an  eruption  in  the  throat,  especially  on 
the  soft  palate.  This  is  usually  the  first  localized  symp- 
tom of  the  disease.  It  consists  of  dusky  red,  more  or 
less  coalescing  spots,  the  injection  usually  spreading 
over  the  tonsils,  and  to  some  extent  over  the  posterior 
wall  of  the  pharynx.  Occasionally  scarlatina  begins 
with  a  distinct  tonsillitis.  In  cases  of  moderate  sever- 
ity the  eruption  fades  as  the  cutaneous  rash  disappears. 
In  a  large  proportion  of  average  and  severe  cases,  how- 

308 


SCARLET  FEVER. — TYPHOID  FEVER.  309 

ever,  there  is  a  secondary  throat  affection  varying  from 
superficial  inflammation  to  formation  of  diphtheritic 
false  membranes  or  even  gangrenous  sloughing.  The 
corresponding  lymph-glands  are  always  swollen  and 
tender.  These  throat  lesions  are  mostly  due  to  infection 
by  streptococci.  Scarlatinous  diphtheria,  however,  is  in 
some  cases  the  result  of  secondary  infection  by  the  diph- 
theria bacillus.  The  diphtheritic  affection,  due  to  the 
streptococcus,  does  not  show  the  tendency  to  extension 
found  in  true  diphtheria.  Extension  to  the  larynx  is  not 
frequent.  But  from  the  start  the  more  severe  forms  of 
throat  affection,  even  those  without  false  membranes, 
show  a  septic  character  and  septic  and  pyemic  sequels  are 
not  uncommon.  Purulent  involvement  of  the  ear  is  like- 
wise a  very  frequent  sequel.  The  throat  affection,  if  of 
any  severity,  may  last  two  to  three  weeks.  Treatment 
has  but  a  moderate  influence.  Antiseptic  gargles  and 
sprays  (thymol  or  the  essential  oil  solution  (see  1  25  and 
1  134) )  are  of  some  service.  The  most  active  but  dis- 
agreeable local  application  is  Loffler's  solution  (1  25). 

The  nose  is  not  involved  as  often  in  scarlet  fever  as  the 
throat.  The  initial  rash  is  said  to  be  visible  on  the 
nasal  mucous  membrane  in  many  instances.  In  a  small 
proportion  of  the  more  severe  cases  a  purulent,  some- 
times a  membranous,  rhinitis  occurs  as  a  sequel.  Autop- 
sies show  that  in  fatal  cases  disease  of  the  nasal  accessory 
cavities  is  quite  common,  but  clinically  this  is  usually 
not  recognizable. 

225.  Small-pox  is  sometimes  ushered  in  by  nasal 
hemorrhages.  They  are  said  to  be  of  more  serious  prog- 
nostic significance  in  adults  than  in  children.  It  is  stated 
that,  as  a  rule,  characteristic  papules  appear  on  the  palate 
and  tonsils  even  earlier  than  on  the  skin,  and  that  these 
follow  the  usual  course  and  change  into  pustules. 

226.  Typhoid  fever  is  attended  by  hemorrhage  from 
the  nose  in  nearly  one-half  the  cases,  especially  in  young 
people.  Occasionally  the  bleeding  is  alarming.  During 
the  later  stage  pharyngitis  is  not  uncommon  and  some- 


3IO  UPPER   AIR-PASSAGES    DURING    OTHER    DISEASES. 

limes  small  oval  ulcers  of  some  persistence  are  seen,  but 
with  little  liability  to  extend. 

2^7.  In  leukocythetnia  nasal  hemorrhages  occur  in 
perhaps  half  the  cases  at  different  times. 

3^8.  Influenza. — This  disease  has  changed  its  char- 
acter considerably  in  different  years  since  its  extension 
throughout  the  world  in  the  form  of  an  epidemic  in  1889. 
In  some  years  nasal  affections  seem  quite  uncommon ;  in 
others  they  are  frequent.  Autopsies  have  shown  the 
frequent  involvement  of  one  or  more  nasal  sinuses.  Prob- 
ably many  of  these  instances  escape  clinical  detection. 
In  others  the  usual  symptoms  of  sinuitis,  especially  of 
the  ethmoid  cells  and  of  the  sphenoid  sinus,  are  present. 
The  sinus  affections  are  more  often  due  to  secondary 
infection  by  streptococci  and  other  germs  than  to  the 
influenza  bacillus  itself.  Some  of  the  influenza  epidemics 
are  complicated  in  many  instances  by  severe  purulent 
rhinitis,  very  liable  to  become  subacute  or  chronic  and 
often  leading  to  early,  sometimes  to  late,  involvement  of 
the  ears.  The  throat  suffers  only  exceptionally  in  this 
disease. 

239.  Herpes. — Herpes  febrilis,  the  familiar  "cold 
sore,"  occasionally  involves  the  pharynx.  This  occur- 
rence is  very  uncommon  in  this  part  of  the  country.  The 
phar>^ngeal  affection  may  occur  in  connection  with  herpes 
of  the  lips  or  sometimes  without  the  latter.  It  begins 
with  a  sharp  fever  lasting  not  over  a  day.  The  herpes 
vesicles  in  the  pharynx  may  be  few  in  number  or  very 
numerous.  The  amount  of  congestion  corresponds  to 
their  number.  Sometimes  they  heal  within  a  few  days; 
more  often  each  vesicle  changes  to  a  superficial  ulcer 
with  yellowish  deposit.  Occasionally  several  coalesce 
and  form  a  diphtheritic-looking  membrane.  This  may 
protract  the  disease  and  confuse  the  diagnostician. 
Herpes  is  said  to  attack  some  persons  in  frequent  relapses 
during  the  whole  life.  If  the  vesicles  do  not  heal  spon- 
taneously within  a  few  days,  the  ulcers  may  be  touched 
with  nitrate  of  silver  with  advantage. 


DIABETES    MELLITUS. — RHEUMATISM.  3II 

230.  A  few  instances  of  herpes  ^joster  of  the  pharynx 
have  been  recorded.  The  vesicles  are  larger  than  in 
febrile  herpes,  and  lead  to  deeper  and  more  lasting 
ulceration.  As  a  rule,  the  spots  are  one-sided.  There  is 
considerable  pain,  sometimes  of  a  neuralgic  order,  and 
its  presence  and  persistence  suggest  the  diagnosis. 

«3i.  Diabetes  mellitus  is  said  to  reveal  itself  often 
by  persistent  dryness  of  the  pharynx.  The  writer  has 
never  observed  this  symptom  in  diabetes.  Recently 
ulceration  of  the  pharynx  has  been  described  as  a  compli- 
cation of  diabetes  (Freudenthal).  The  ulcers  on  the  ton- 
sil, pillar,  posterior  wall,  or  base  of  the  tongue  may  be 
superficial  or  may  extend  deeper.  They  resemble  tuber- 
cular ulcers,  but  bacilli  cannot  be  found,  and,  unlike 
tubercular  disease,  they  can  be  readily  cured.  The  pain 
which  they  cause  interferes  considerably  with  nutrition. 

232.  Rheumatism. — Rheumatism  has  no  relation  to 
any  nasal  lesion,  but  it  is  very  frequently  referred  to  by 
authors  as  an  etiologic  factor  in  tonsillitis.  This  is 
partly  due  to  a  misconception  as  to  cause  and  effect.  A 
number  of  observers  have  noted  that  rheumatism  may 
follow  acute  tonsillitis.  Indeed,  tonsillitis  is  a  frequent 
antecedent  in  attacks  of  acute  rheumatism,  so  much  so 
that  the  latter  must  be  regarded  in  many  instances  as  the 
consequence  of  an  inflammation  of  the  tonsil.  It  is,  how- 
ever, an  open  question  whether  this  is  ordinary  tonsillitis 
or  an  inflammation  due  to  the  invasion  by  the  specific,  as 
yet  not  identified,  virus  of  rheumatism.  The  tonsillar 
origin  of  rheumatism  has  been  stated  as  high  as  80  per 
cent.  (Fowler).  But  most  observers  give  very  much 
lower  figures  (5  to  20  per  cent.).  It  has  also  been  noted 
that  patients  with  the  history  of  former  rheumatism  are 
prone  to  attacks  of  acute  tonsillitis.  But  the  frequency 
of  this  factor  in  the  etiology  of  tonsillitis  is,  after  all,  a 
very  small  one  when  compared  with  the  prevalence  of 
tonsillitis,  especially  in  children.  Even  in  distinctly 
rheumatic  subjects   acute  tonsillitis  follows  its  ordinary 


312  UPPER    AIR-PASSAGES    DURING    OTHER    DISEASES. 

rapid  course  and  is  not  influenced  to  any  demonstrable 
extent  by  antirheumatic  treatment. 

Some  forms  of  chronic  tonsillitis  have  been  ascribed  to 
a  rheumatic  basis.  The  descriptions  of  different  authors 
are,  however,  so  discordant,  and  their  criteria  of  rheu- 
matic origin  so  indefinite,  that  no  positive  conclusions 
can  be  stated.  The  writer's  personal  experience  has 
made  him  familiar  with  a  form  of  sore  throat  of  indefinite 
duration,  fairly  frequent,  which  in  most  cases  can  be 
influenced  promptly  by  the  liberal  use  of  salicylate  of 
sodium.  The  patient  complains  of  pain  in  swallowing, 
which  he  cannot  localize.  Inspection  shows  some  diffiise 
redness,  but  no  localized  inflammation  of  the  mucous 
membrane.  The  lesion  is  in  all  probability  a  rheumatic 
inflammation  of  the  fibrous  fascia  of  the  pharynx,  and 
not  an  affection  of  the  mucous  membrane. 

233.  lodism. — The  internal  use  of  salts  of  iodin  pro- 
duces, in  some  persons,  symptoms  of  nasal  irritation. 
The  patient  feels  "dumpish,"  the  head  is  "stuffy,"  the 
nose  full  and  obstructed,  like  in  a  fresh  "cold,"  and 
secretes  an  abundant  thin  mucus,  but  no  pus.  This  may 
or  may  not  be  associated  with  other  evidences  of  iodin 
poisoning,  such  as  acne  pustules,  foul  breath,  and  dis- 
ordered stomach.  Inspection  shows  turgescence  of  the 
nasal  lining,  but  not  necessarily  any  hyperemia.  As  a 
rule,  the  nasal  irritation  subsides  within  a  day  on  with- 
drawing the  drug,  or  it  may  even  cease  in  spite  of  its 
continuance  in  larger  doses.  Very  rarely  it  changes  to  a 
purulent  rhinitis.  Iodic  irritation  of  the  nose  is  due  to 
the  "idiosyncrasy"  of  some  patients,  and  may  come  on 
even  after  small  doses.  Unless  severe  or  persistent,  it 
need  not  prevent  the  continued  administration  in  in- 
creasing doses. 


CHAPTER  XXVII. 

TUMORS  OF  THE  NOSE  AND  PHARYNX. 

234.  Neoplasms  within  the  nasal  cavity  are  of  un- 
common occurrence  aside  from  the  inflammatory  hy- 
pertrophies— viz.,  polypi  and  papillomata.  Polypi  are 
found  clinically  in  about  2  per  cent,  of  nasal  patients, 
but  in  dissections  of  unselected  subjects  Zuckerkandl 
saw  polypi  present  in  about  10  per  cent.  Papillomata 
are  considerably  less  frequent.  These  overgrowths  of 
inflammatory  origin  have  been  described  in  1  99  to  1 104. 
In  the  present  place  it  is  necessary  to  refer  to  them 
simply  from  a  diagnostic  point  of  view,  and  in  order  to 
point  out  their  relation  to  other  growths.  A  variety  of 
nasal  tumors,  both  benign  and  malignant,  can  assume 
a  polypoid  shape,  and  may  hence  be  mistaken  for  mu- 
cous polypi.  Such  polypoid  shape  may  be  assumed  by 
a  hard  fibroid,  an  angioma,  sarcoma,  adenoma,  car- 
cinoma, and  syphilitic  or  tubercular  granulomatous 
tumors.  From  all  these  the  true  mucous  polypus  can  be 
distinguished  by  its  smooth,  glistening  surface,  its  rela- 
tive softness  without  tendency  to  bleeding,  and  in  most 
instances  its  edematous  condition,  while  its  color  varies 
from  that  of  the  normal  mucous  membrane  slightly  in- 
jected to  a  yellowish-gray  gelatinous  appearance  when 
markedly  edematous.  Polypi  may,  however,  be  asso- 
ciated with  other  tumors,  especially  angiomata,  so  that 
in  complicated  cases  the  diagnosis  is  not  always  simple. 
Polypi  grow  mainly  from  the  middle  turbinal  and  the 
various  ethmoid  lamellae.  They  have  been  very  rarely 
seen  attached  to  the  septum. 

235.  Next  in  order  of  frequency  are  the  papillomata. 
In  well-marked  instances  these  wart-like  tumors  are  of 
raspberry  or  mulberry  shape,  of  reddish  or  violet  hue, 

313 


314        TUMORS  OF  THE  NOSE  AND  PHARYNX. 

sometimes  single,  sometimes  multiple.  From  the  typical 
papillomata  as  large  as  a  cherry  there  are  all  gradations 
down  to  the  most  insignificant,  scarcely  circumscribed, 
hypertrophic  elevation  of  the  mucous  membrane.  This 
tumor,  like  the  polypus,  is  of  inflammatory  origin,  and 
usually  associated  with  purulent  rhinitis.  Its  favorite 
site  is  somewhere  on  the  inferior  turbinal,  less  often  on 
the  nasal  floor.  It  is  not  frequently  met  with  on  the 
septum.  When  found  at  the  front  of  the  septum  the 
papilloma  resembles  the  cutaneous  wart  by  its  decided 
cauliflower  appearance,  due  to  indentation  by  its  pro- 
liferated epithelium.  These  hard  septal  papillomata 
are  regarded  with  distrust  on  account  of  their  possible 
transformation  into  malignant  epithelioma,  especially  in 
elderly  people. 

236.  Nasal  tumors  produce  at  first  very  little  dis- 
turbance. The  obstruction  to  breathing  is  not  pro- 
nounced until  at  a  late  stage,  and  is  often  ignored  by  the 
patient.  It  is  hence  quite  rare  that  tumors  are  seen  at  an 
early  period.  The  one  symptom  which  leads  most  fre- 
quently to  their  early  detection  is  bleeding  from  the  nose. 

237*  The  tumor  which  more  than  any  other  reveals 
itself  by  bleeding  is  the  "bleeding  polypus  of  the  septum." 
It  is  a  single  polypoid  excrescence  on  the  septum,  of  the 
size  of  a  shot  to  that  of  a  pea,  bleeding  freely  on  touch. 
It  is  always  one-sided.  It  is  rarely  found  in  men,  mostly 
in  adult  women.  In  structure  it  is  either  granulation 
tissue  with  dilated  vessels,  or  a  pure  angioma  or  a  mixed 
fibro-angioma.  Its  only  significance  is  its  liability  to 
bleed  and  its  recurrence  after  incomplete  operation.  It 
should  be  radically  removed  by  the  snare  (and  curet)  or 
the  galvanocaustic  burner. 

238.  Another  form  of  bleeding  tumor  is  the  pure  or 
mixed  angioma  in  other  sites.  Although  not  frequent, 
these  growths  are  of  considerable  importance,  on  account 
of  the  very  free  bleeding  to  which  they  may  give  rise. 
This  vascular  tumor  appears  of  the  color  of  the  normal 
mucous  membrane,  is  soft,  even  flabby,  and  bleeds  upon 


HARD    FIBROMA. — CYSTS. 


315 


the  slightest  touch.  It  springs  mainly  from  the  external 
wall  in  the  form  of  a  diffuse  tumefaction,  sometimes 
lobulated  enough  to  be  polypoid  in  shape.  It  is  made  up 
of  cavernous  tissue,  dilated  venous  channels  with  thin 
walls.  On  account  of  the  prevalence  of  cavernous  tissue 
throughout  the  nose,  different  nasal  tumors,  such  as  sar- 
comata, adenomata,  and  at  times  even  harmless  mucous 
polypi  are  apt  to  be  in  part  of  angiomatous  structure, 
which  point  must  be  remembered  in  the  diagnosis.  The 
unmixed  angiomata  may  extend  into  adjoining  spaces 
like  the  orbit,  and  may  thus  prove  quite  annoying, 
although  not  at  all  malignant.  Vascular  tumors  can  be 
safely  removed  with  a  cold  snare,  provided  they  can  be 
thoroughly  grasped.  It  is  necessary  to  use  a  snare  with 
screw-nut,  which  can  be  drawn  home  very  slowly  in 
order  to  avoid  hemorrhage.  When  the  snare  cannot  be 
satisfactorily  used,  the  attachment  of  the  growth  may  be 
cut  through  with  the  knife-shaped  burner  in  a  series  of 
sittings.  The  surgeon  must  be  prepared,  however,  for 
very  copious  hemorrhage.  Electrolysis  by  means  of 
needles  inserted  near  the  base  of  the  tumor  is  lauded  by 
some,  condemned  by  others.  It  requires  a  current  of  10 
to  25  or  even  more  milliamperes  for  five  to  ten  minutes 
at  a  time,  with  many  repetitions  at  intervals  of  a  few 
days. 

239.  The  hard  fibroma  is  a  rare  form  of  nasal  growth, 
which  may  become  serious  by  pressure,  on  account  of  its 
continually  increasing  size.  It  is  a  firm  fibrous  structure 
with  broad  pedicle.  When  detected  early,  it  can  be 
removed  with  a  snare.  But  after  it  has  filled  the  nasal 
cavity  or  extended  beyond  its  confines,  it  may  require 
a  major  external  operation  in  order  to  gain  access  to  it. 

240.  Cysts  are  a  frequent  occurrence  in  the  maxillary 
and  frontal  sinuses,  but  very  uncommon  in  the  nasal 
cavity.  In  rare  instances  a  glandular  retention  cyst  is 
found  on  the  floor  or  on  the  external  wall.  Even  less 
common  is  the  development  of  a  cyst  in  the  septum 
secondary  to  a  hematoma  which  has  not   gone  to  sup- 


3l6  TUMORS    OF   THE    NOSE   AND    PHARYNX. 

puration.  The  diagnosis  of  the  cystic  nature  of  the  soft 
globular  tumor  can  be  established  by  puncture  with  a 
hollow  needle.  A  radical  cure  requires  either  removal 
of  the  greater  part  of  the  cyst-wall  or  obliteration  by 
injection  of  tincture  of  iodin,  which  is  not  always  suc- 
cessful. 

241.  Osteoma  is  a  rare  form  of  nasal  tumor  springing 
from  the  floor  or  external  wall,  or  originating  in  one  of 
the  accessory  cavities.  Its  nature  is  recognized  by  its 
hardness.  Its  seriousness  depends  on  its  rate  of  growth 
and  the  displacement  of  tissue  and  organs  to  which  it 
ultimately  leads.  If  accessible  by  the  intranasal  method,* 
it  can  be  removed  without  much  danger,  b:i .  its  hardness 
is  such  that  it  is  necessary  to  chisel  thiough  the  healthy 
bone  from  which  it  springs.  If  too  large  to  be  accessible 
from  the  nose,  it  may  require  a  formidable  operation  in 
order  to  be  removed.  Even  less  common  are  cartilagin- 
ous tumors, — chondromata, — originating  from  the  septum 
or  sometimes  from  the  ethmoid  bone.  These  growths 
are  apt  to  become  detached  from  their  matrix,  being  con- 
nected in  that  case  only  by  means  of  a  bridge  of  mucous 
membrane.  When  seen  at  this  stage,  their  removal  is 
very  easy. 

24a.  Spurs  and  ridges  on  the  septum  which  are  some- 
times referred  to  as  exostoses  and  ecchondroses  should 
not  be  classified  among  tumors  for  reasons  given  in  1  114 
and  T[  115.  The  beginner  should  also  be  cautioned 
against  the  mistake  of  taking  an  expanded  middle  tur- 
binal  for  a  true  tumor. 

Reference  must  again  be  made  to  the  occasional,  though 
rare,  occurrence  of  granulomatous  tumors  due  either  to 
tuberculosis  or  even  more  rarely  to  syphilis.  Either 
tumor  appears  as  a  fleshy  growth,  readily  bleeding  on 
touch,  the  tuberculoma  being  the  least  firm  of  the  two. 
The  site  is  preferably  on  the  septum,  less  commonly  on 
the  floor  or  external  wall.  Both  of  these  forms  of  morbid 
growth  are  attended  with  seropurulent  discharge,  which 
in  tubercular  disease  is  usually  ver)'  fetid.    These  tumors 


OSTEOMA.  3  1 7 

may  prove  puzzles  to  the  diagnostician.  Microscopically 
they  consist  of  rather  firm  granulation  tissue,  in  part 
even  fibrous.  Tubercles  may  not  be  found  except  in 
some  parts.  Giant  cells  are  met  with  both  in  syphilis 
and  in  tuberculosis.  Tubercle  bacilli,  if  present  at  all, 
are  scant  in  number.  In  the  syphilitic  tumors  the  arte- 
rial walls  are  found  thickened  and  infiltrated.  If  the 
history  or  concomitant  lesions  or  the  microscopic  ex- 
amination does  not  clear  the  diagnosis,  it  may  have  to  be 
based  upon  the  result  of  a  diagnostic  tuberculin  injection 
or  a  week's  employment  of  iodid  of  potassium  in  large 
doses. 

^43'  Of  malignant  tumors,  sarcoma  is  more  frequent 
in  the  nose  than  true  cancer.  Both,  however,  are  very 
rare.  The  former  is  more  likely  to  grow  rapidly,  dis- 
placing the  nasal  walls,  but  less  likely  to  ulcerate  early, 
and  hence  to  bleed,  than  carcinoma.  The  latter  is  also 
more  apt  to  be  painful.  Sarcoma  is  essentially  a  disease 
of  youth;  carcinoma,  of  more  advanced  age.  Either 
tumor  presents  itself  as  a  firm  reddish  mass,  often  with 
eroded  or  ulcerated  surface,  and  liable  to  bleed,  especially 
when  mixed  with  overgrown  cavernous  tissue.  The 
sarcoma  is  sometimes  pigmented.  Such  a  melanosarcoma 
is  not  always  as  malignant  in  the  nose  as  it  is  in  other 
localities.  The  diagnosis  cannot  generally  be  made  until 
after  microscopic  examination  of  a  fragment,  and  even 
this  may  prove  indecisive.  Unless  radically  removed, 
these  malignant  tumors  give  a  bad  prognosis.  Their 
removal  is  generally  a  quite  formidable  operation.  Ma- 
lignant tumors  may  escape  detection  until  a  late  period 
if  they  originate  in  the  maxillary  or  frontal  sinus. 

244.  A  tumor  formed  by  the  proliferation  of  the  mucous 
glands,  the  so-called  adenoma,  is  intermediate  between 
benign  and  malignant  tumors.  The  pure  adenoma  is 
probably  extremely  rare.  Most  of  these  growths  are 
more  of  the  nature  of  a  true  cancer.  Relatively  often  it 
is  a  mixed  type — adenoma  with  angioma.  The  writer's 
experience  has  probably  been  exceptional  in  observing  a 


3l8        TUMORS  OF  THE  NOSE  AND  PHARYNX. 

radical  cure  for  at  least  three  years  after  the  intranasal 
removal  of  a  pure  adenoma  in  an  old  man. 

245.  In  the  pharynx  tumors,  in  the  proper  sense  of  the 
word,  are  likewise  not  common.  Hypertrophy  of  the 
pharyngeal  tonsil  cannot  be  called  a  true  neoplasm.  In 
examining  the  upper  pharynx,  especially  when  exploring 
with  the  finger,  the  beginner  should  not  be  misled  by  an 
exceptional  prominence  of  the  first  cervical  vertebra, 
which  may  simulate  a  morbid  swelling.  Edematous 
polypi^  which  are  sometimes  found  in  the  nasal  pharynx, 
are,  as  a  rule,  of  nasal  origin,  having  grown  beyond  the 
posterior  choanae.  The  appearance  of  such  a  growth 
when  seen  in  the  mirror  is  like  that  of  the  ordinary 
nasal  polypus.  Its  removal  by  the  nasal  or  curved  post- 
nasal snare  may  be  quite  difficult.  Lange  has  suggested 
the  use  of  a  small  stout  blunt  hook,  introduced  through 
the  nose,  by  means  of  which  the  growth,  supported  as  it 
is  by  the  bony  rim  of  the  choanae,  can  be  torn  from  its 
attachment. 

246.  The  most  common,  though  by  no  means  a  fre- 
quent, neoplasm  in  the  nasal  pharynx  is  the  hard  fibroid. 
It  occurs  almost  exclusively  in  boys,  and  if  not  previously 
fatal,  it  is  said  to  disappear  spontaneously  about  the 
twenty-fifth  year  of  life.  It  is  a  firm  fleshy  tumor  spring- 
ing from  the  roof  of  the  pharynx  or  the  bony  rim  of  the 
choanae  by  a  broad  or  often  a  multiple  pedicle.  It  is  apt 
to  become  eroded  or  ulcerated,  and  may  then  attach  itself 
by  adhesion  to  other  surfaces.  Felt  at  first  only  as  a 
foreign  body,  the  presence  of  which  affects  the  voice  and 
excites  efforts  at  hawking,  it  becomes  formidable  as  it 
continues  to  grow.  Although  not  very  vascular,  it  bleeds 
in  many  instances,  often  to  an  extent  creating  extreme 
anemia.  Drowsiness  is  often  noted  as  its  symptom. 
The  ulceration  of  its  surface  may  cause  sepsis,  sometimes 
fatal.  When  allowed  to  grow,  it  fills  the  entire  upper 
pharynx  and  occludes  it  absolutely.  It  may  extend  to 
the  nasal  chambers  and  expand  the  lateral  walls,  causing 
the  disfiguring  flattening  of  the  face  known  as  frog  face. 


POSTNASAL  FIBROIDS.  319 

Exceptionally  it  grows  through  the  roof  of  the  pharynx  or 
nose,  enters  the  cranial  cavity,  and  kills  by  some  cranial 
complication. 

347.  The  removal  of  a  postnasal  fibroma  may  prove 
very  difficult.  The  cold  snare  can  generally  not  cut 
through  its  firm  base.  When  the  attachment  is  well 
accessible,  the  hot  snare  may  answer.  Considerable 
hemorrhage  may  be  expected.  Electrolysis  has  been 
employed  with  fair  success.  It  requires,  however,  many 
sittings,  sometimes  months,  until  the  detachments  have 
either  shrunk  sufficiently  or  sloughed  so  as  to  permit 
complete  removal.  A  current  of  more  than  20  or  25 
milliamperes  cannot  be  tolerated  without  narcosis.  With 
anesthesia,  currents  of  two  to  three  times  that  strength 
have  been  employed.  But  even  in  that  case  many  repe- 
titions are  necessary.  When  no  urgent  symptoms  are 
present,  electrolysis  may  be  considered  the  safest  mode 
of  operating,  and  its  tediousness  may  be  shortened  by 
finishing  with  a  hot  snare  as  soon  as  feasible.  When 
these  measures  prove  inapplicable,  or  when  rapid  removal 
is  indicated,  access  to  the  postnasal  space  must  be  gained 
by  some  preliminary  operation.  The  least  formidable 
one  is  the  splitting  of  the  soft  palate  in  the  median  line 
(leaving  the  uvula  on  one  side).  When  fully  accessible, 
the  growth  is  dissected  out,  hemorrhage  controlled  by  a 
tampon,  and  the  palate  sutured.  In  the  case  of  large 
growths  this  method  is  rarely  sufficient,  and  more  exten- 
sive operations  are  required,  either  by  a  temporary  re- 
section of  the  superior  maxilla  or  by  entering  through 
the  side  of  the  pharynx.  The  operation  becomes  one  of 
considerable  magnitude  and  danger. 

Fibrous  tumors  are  found  in  the  lower  part  of  the 
pharynx  to  a  much  less  extent.  Being  easily  accessi- 
ble, they  can  be  recognized  earlier  and  removed  without 
much  difficulty. 

248.  The  most  common  of  all  pharyngeal  neoplasms 
are  papillomata.  In  this  locality  their  surface  is  always 
more   or  less  cleft,  like  cauliflower,  and   the  relatively 


320        TUMORS  OF  THE  NOSE  AND  PHARYNX. 

thick  epithelium  gives  them  a  firm  consistency.  They 
are  found  mostly  on  the  pillars  or  the  uvula,  sometimes 
hanging  by  a  long  thin  pedicle. 

249.  Vascular  tumors  have  been  met  with  in  the  phar- 
ynx, especially  on  the  tonsils.  They  vary  from  a  superficial, 
nevus-like  spot  of  vascularity  to  a  tumor-shaped  angioma. 
In  the  former  case  the  condition  is  harmless  and  usually 
stationary,  and  requires,  as  a  rule,  no  treatment.  In  the 
latter  case  the  presence  of  the  protruding  tumefaction, 
the  liability  to  further  growth,  and  especially  to  bleeding, 
render  operation  necessary.  The  snare,  hot  or  cold, 
should  be  used  only  if  it  can  be  applied  to  the  base  of  the 
growth  beyond  the  area  of  dilated  vessels,  otherwise  an 
uncontrollable  hemorrhage  may  result.  If  the  shape  of 
the  growth  does  not  permit  the  use  of  the  snare,  it  may 
be  dissected  out  with  the  knife-shaped  burner,  preferably 
in  one  sitting.  Under  some  conditions  of  inaccessibility 
the  better  plan  is  to  puncture  the  base  of  the  growth  with 
the  pointed  galvanocaustic  burner,  and  thus  induce  gra- 
dual shrinkage  and  formation  of  an  artificial  pedicle,  per- 
mitting subsequently  an  easier  removal.  In  this  case  it 
is  usually  safer  to  puncture  into  healthy  tissue  beyond 
the  growth.  Electrolysis  has  also  been  utilized  in  this 
condition.  It  is  easily  manageable  and  fairly  safe,  but 
its  extreme  tediousness  is  an  objection, 

250.  Some  peculiarities  are  presented  by  tumors  grow- 
ing in  the  soft  palate  between  its  buccal  and  nasal  sur- 
faces. They  have  been  termed  intramural  tumors.  The 
majority  of  them  are  benign — a  fibroma  or  rarely  a  cyst 
or  a  lipoma,  but  occasionally  an  adenoma  or  a  malignant 
sarcoma.  In  either  case  the  tumor  is  encapsulated  and  not 
difficult  to  dissect  out  from  the  buccal  side.  The  diagnosis 
of  the  nature  of  the  tumor  cannot  generally  be  made 
until  after  its  removal. 

251.  Malignant  tumors  in  the  phar^'nx  are  not  much 
less  frequent  than  benign  growths.  Of  these,  cancer  is 
rather  more  often  seen  than  sarcoma,  the  former  espe- 
cially in  advanced  life,  the  latter  in  youth.     The  symp- 


MALIGNANT   TUMORS.  32 1 

toms  may  remain  trivial  for  some  months.  Gradual 
interference  with  speech  and  deglutition,  pharyngeal 
irritation,  and  secretion  lead  to  their  detection.  Carci- 
noma is,  as  a  rule,  painful  in  its  late  stages.  Either 
tumor  may  finally  cause  starvation  on  account  of  the 
difficulty  in  swallowing.  The  main  sites  are  the  tonsil, 
the  lingual  tonsil,  and  the  palate.  The  posterior  wall  is 
least  often  affected,  and  if  at  all,  more  likely  secondary  to 
a  laryngeal  growth.  Sarcoma  is  rather  a  more  distinctly 
circumscribed  tumor  than  carcinoma,  which  appears  and 
spreads  usually  as  a  diffused  infiltration  with  early  ulcera- 
tion. In  sarcoma  ulceration  occurs  later,  if  at  all.  The 
breaking  down  of  the  growth  gives  rise  to  awful  fetor  of 
the  breath.  Cachexia  becomes  marked  by  this  time,  and 
may  become  complicated  by  sepsis.  Subacute  inflam- 
matory attacks  frequently  start  from  the  growth,  and  some- 
times cause  much  inflammatory  edema.  Corrosion  of  large 
arterial  twigs,  occasionally  with  fatal  hemorrhage,  has  been 
observed.  Unless  a  radical  operation  is  feasible,  death  is 
only  a  question  of  time.  In  the  diagnosis  of  malignant 
growths,  especially  of  carcinoma,  all  obtainable  evidence 
must  be  carefully  weighed  in  order  to  decide  between 
this  process,  syphilitic  chancre,  gumma,  and  tuberculosis. 
The  cervical  lymph-glands  are  enlarged  early  in  can- 
cer and  primary  syphilitic  sores;  often,  but  not  always, 
in  tuberculosis,  and,  as  a  rule,  not  at  all  in  sarcoma  and 
gumma. 
21 


CHAPTER   XXVIII. 

FOREIGN  BODIES  IN  THE  UPPER  AIR-PASSAGES. 
RHINOLITHS.  ANIMAL  PARASITES.  SURGICAL 
INJURIES  AND  FRACTURES.  CICATRICIAL  CON- 
TRACTIONS IN  THE  PHARYNX. 

25^.  Foreign  bodies  get  into  the  nose  principally  in 
consequence  of  mischievous  pranks  of  children.  Beads, 
beans  and  peas,  seeds  and  kernels,  small  buttons,  paper 
wads,  and  similar  articles  are  the  most  likely  objects. 
Bullets  and  fragments  resulting  from  an  explosion  occa- 
sionally remain  lodged  in  the  nose  after  perforating  the 
facial  bones  or  migrating  with  suppurative  inflammation. 
Rarely  do  solid  pieces  of  food,  bits  of  bone,  etc.,  enter 
the  posterior  choanse  by  reason  of  coughing  while  swal- 
lowing or  during  vomiting.  Equivalent  to  foreign 
bodies  are  concretions  formed  in  place,  the  rhinoliths. 
They  are  hard  bodies,  consisting  principally  of  phosphate 
of  calcium.  As  a  rule,  they  form  around  a  foreign  parti- 
cle as  a  nucleus,  sometimes  around  a  bit  of  inspissated 
pus.  They  occur  especially  in  workmen  in  cement  fac- 
tories and  lime-works.  In  other  instances  their  origin 
is  obscure.  They  may  be  of  any  size  up  to  that  of  a 
plum-kernel  or  even  larger,  sometimes  smooth  and  oval, 
or  again  of  irregular  shape  and  rough.  Their  color  is 
quite  variable. 

Foreign  bodies  are  lodged  mostly  in  the  inferior  nasal 
meatus,  but  may  be  impacted  anywhere.  Unless  smooth 
and  bland,  they  are  rarely  tolerated  long  without  causing 
inflammation,  with  purulent  or  seropurulent  discharge, 
sometimes  bloody,  almost  always  offensive,  and,  of  course, 
ordinarily  one-sided.  Such  a  discharge  should  raise  a 
suspicion  of  foreign  body,  especially  in  young  children, 

322 


FOREIGN    BODIES.  -  ANIMAL    PARASITES.  323 

in  whom  suppurative  sinuitis  is  very  rare.  Granulations 
are  apt  to  form  around  the  offending  substance  and  may 
hide  it  from  view.  Ulceration,  even  perforation  of  the 
septum,  can  be  caused  by  sharp-cornered  bodies,  especially 
rhinoliths.  Under  these  circumstances  distant  distur- 
bances, headache,  especially  one-sided,  and  even  asthma 
are  not  uncommon.  Nevertheless,  foreign  bodies  have 
sometimes  been  endured  by  patients  for  years  and  es- 
caped detection. 

The  diagnosis  depends  upon  feeling  the  foreign  body 
with  the  probe.  Its  removal  may  require  tact,  especially 
when  dealing  with  a  child.  When  recently  introduced  and 
not  impacted,  a  foreign  body  like  a  button  can  often  be 
blown  out  by  forcing  air  through  the  other  nostril,  ac- 
cording to  Politzer's  method  of  inflation  of  the  ear.  If 
forced  back  by  blowing  into  the  involved  side,  the  sub- 
stance enters  the  pharynx  and  may  be  swallowed.  When 
this  method  fails,  the  simplest  way  is  to  grasp  the  body 
with  stout  forceps  with  scoop-shaped  or  large  perforated 
blades  and  to  extract  it.  An  unruly  child  requires  nar- 
cosis. Good  illumination  is  indispensable.  In  the  case 
of  round,  smooth  substances,  especially  when  far  back  in 
the  nose,  a  spoon-shaped  curet  is  often  better  than  forceps. 
If  the  purulent  rhinitis  does  not  subside  within  a  few  days 
after  extraction,  it  should  be  treated  according  to  1  34. 

253.  A  special  form  of  foreign  bodies,  found  a  number 
of  times  in  the  nose,  are  animal  parasites — the  maggots  of 
various  species  of  flies,  and  particularly  the  screw-worn. 
They  may  be  present  in  large  numbers  and  extend  into 
the  maxillary  and  frontal  sinuses,  causing  violent  sup- 
purative sinuitis.  Their  presence  causes  always  much 
inflammatory  reaction  and  often  extensive  ulceration. 
Death  from  cranial  involvement  or  sepsis  has  occurred  in 
a  noticeable  proportion  of  reported  cases.  The  diagnosis 
is  evident  when  maggots  or  worms  are  found  on  searching 
with  forceps.  It  has  not  always  been  found  possible  to 
remove  all  parasites  mechanically.  Probably  the  least 
objectionable   antiparasitic  poison   is   chloroform   vapor 


324  INJURIES    OF    THE    UPPER    AIR-PASSAGES. 

blown  through  the  nostrils,  while  the  patient  breathes 
through  the  open  mouth. 

As  an  exceptional  occurrence  the  intestinal  parasitic 
worms,  ascaris  or  oxyuris,  have  been  found  in  the  nasal 
cavity  and  the  maxillary  sinus. 

254.  Foreign  bodies  may  get  into  the  maxillary  sinus 
through  an  artificial  opening,  especially  when  in  the 
alveolar  process.  Fragments  of  surgical  instruments, 
metal  cannulse,  remnants  of  gauze,  etc.,  may  maintain 
suppurative  inflammation  until  removed.  If  not  felt  by 
the  probe,  when  suspected  they  may  be  demonstrated  by 
an  X-ray  photograph,  if  of  a  material  opaque  to  those 
rays. 

355*  In  the  pharynx  sharp  foreign  bodies  get  caught 
when  accidentally  swallowed  or  aspirated.  Fish-bones 
and  pins  are  the  commonest  objects,  and  they  are  usually 
found  in  the  tonsil  or  impacted  in  the  pyriform  sinus 
between  tongue  and  epiglottis.  It  is  sometimes  difficult 
to  see  them.  When  found,  they  can  be  grasped  by  any 
forceps  with  broad  ends. 

256.  With  the  exception  of  fractures  of  the  external 
nose  surgical  injuries  extend  very  rarely  into  the  nose  or 
the  pharynx.  Although  traumatism  accounts  for  a  mod- 
erate number  of  septum  deformities,  its  frequency  has 
been  much  overrated  in  some  books.  It  is  true  that 
violence  to  the  external  nose  is  very  common  in  children, 
but  it  cannot  break  the  septum  unless  it  smashes  or  dis- 
locates the  bridge  of  the  nose.  This  statement  is  based 
upon  tests  on  the  noses  of  cadavers  by  Zuckerkandl,  as 
well  as  upon  his  dissections  of  (united)  fractures  of  the 
septum.  The  history  of  a  blow  some  time  ago  in  the 
case  of  a  septum  deformity  is  not  proof  that  the  latter 
resulted  therefrom,  unless  the  nasal  obstruction  appeared 
at  once  after  the  accident.  Traumatic  bleeding  from  the 
nose  occurs  so  readily  that  a  fracture  cannot  be  inferred 
merely  on  account  of  epistaxis.  Fracture  with  or  with- 
out dislocation  of  the  nasal  bones  can  be  easily  detected 
soon  after  the  accident,  but  within  a  few  hours  the  swell- 


FRACTURES  OF  THE  EXTERNAL  NOSE,         325 

ing  may  be  so  intense  that  nothing  can  be  made  out.  Of 
course,  such  extreme  swelling  is  by  itself  highly  sus- 
picious of  fracture  of  the  bridge  of  the  nose.  If  the 
fracture  is  complicated  by  tearing  of  the  mucous  surface, 
gaseous  distention — emphysema  of  the  face — may  happen 
when  the  patient  sneezes.  The  interior  of  the  nose  should 
be  promptly  examined  whenever  the  bridge  is  broken. 
A  fracture  of  the  septum  involves  always  the  cartilagin- 
ous part.  The  ethmoid  perpendicular  plate  will  break 
only  from  intense  violence;  the  vomer,  never.  The  line 
of  fracture  is  usually  nearly  horizontal,  rarely  vertical, 
sometimes  multiple.  As  a  rule,  the  fracture  is  a  simple 
one  with  intact  mucous  membrane.  The  fragments  of 
the  septum  may  override  more  or  less.  There  may  also 
be  dislocation  and  lateral  displacement  of  the  cartilagin- 
ous plate  at  its  junction  with  the  vomer.  Occasionally 
a  fracture  of  the  nasal  bones  causes  only  bending,  but  no 
fracture  of  the  septum.  In  the  bony  septum  the  reunion 
is  ultimately  due  to  callus,  while  the  cartilaginous  frag- 
ments are  merely  joined  by  connective  tissue.  Unless  a 
broken  septum  heals  with  accurate  adaptation  of  the  frag- 
ments, there  will  always  remain  more  or  less  nasal  ob- 
struction. Fracture  of  the  nasal  bones  leaves  flattening 
of  the  bridge  of  the  nose  proportionate  to  the  dislocation 
of  the  fragments.  Not  infrequently  disfiguring  asymmetry 
of  the  external  nose  results  from  a  break  of  the  bridge 
and  septum. 

When  the  patient  is  seen  before  firm  union  of  the 
fractured  bones  has  taken  place,  every  eifort  should  be 
made  to  restore  the  plane  of  the  septum  and  the  shape  of 
the  external  nose.  Immediate  firm  tamponing  of  the 
nasal  passages  with  gauze  has,  on  the  whole,  given  the 
best  results.  The  bridge  should  be  lifted  from  the  inte- 
rior with  the  largest  rod  or  thickest  probes,  which  can  be 
introduced  and  the  septum  straightened  in  the  same  man- 
ner. Broad  forceps,  especially  the  Asch  pattern,  used  in 
the  operation  for  deflected  septum  (Fig.  66),  may  aid  in 
reducing  the  dislocation  of  the  septal  fragments.     Narco- 


J[26  INJURIES    OF    THE    UPPER    AIR-PASSAGES. 

sis  should  be  used  if  necessary.  The  nasal  passages  should 
then  be  firmly  packed  with  gauze  on  both  sides,  necessi- 
tating, of  course,  mouth-breathing.  After  a  few  days  the 
Asch  or  Meyer  rubber  tube  (1  119)  may  be  substituted 
for  the  gauze  in  the  lower  part  of  the  passage.  If  the 
comminution  and  impaction  of  the  bridge  of  the  nose  are 
such  that  the  normal  shape  cannot  be  restored  by  manipu- 
lation, the  tendency  of  modern  surgery  is  to  reach  the 
fragments  by  an  external  incision — of  course,  under 
asepsis — and  to  retain  them  in  place,  if  necessary  by 
wiring.  In  the  interior  no  incisions  are  ever  required. 
When  a  faulty  union  has  begun,  it  is  better  to  await  the 
final  (partial)  absorption  of  the  callus  than  to  refracture 
at  the  time.  The  later  appearances  of  a  fractured  septum 
have  been  described  in  1  116. 

257.  Cicatricial  changes  after  ulceration  may  interfere 
with  the  function  of  the  pharynx  to  a  variable,  sometimes 
an  extreme  extent.  The  most  common  lesion  is  adhe- 
sion of  one  or  even  both  posterior  pillars  to  the  posterior 
wall,  possibly  to  an  extent  separating  practically  the 
nasopharynx  from  the  oral  pharynx.  In  other  instances 
the  anterior  pillars  may  be  so  contracted  that  the 
palate  cannot  reach  the  posterior  wall.  Scars  in  the 
region  of  the  lingual  tonsil  may  narrow  the  fauces,  A 
variable  part  of  the  palate  may,  besides,  have  been  lost, 
•which,  however,  is  not  so  common  as  a  mere  perforation. 
Narrowing  of  the  pharynx  by  cicatricial  changes  in  the 
posterior  wall  is  less  common.  In  the  nasopharynx  there 
may  be  adhesions  between  the  Eustachian  prominence 
and  the  posterior  wall,  bridging  over  or  obliterating  the 
fossa  of  Rosenmiiller.  The  two  Eustachian  orifices  have 
been  seen  united  by  a  transverse  bridge. 

The  most  frequent  cause  of  pharyngeal  shrinkage  is 
said  to  be  scleroma  in  those  countries  where  it  is  preva- 
lent, especially  Poland.  With  us,  tertiary  syphilis 
ranks  first.  Tuberculosis  is  rare  and  heals  even  less  fre- 
quently. Diphtheria  can  do  much  damage  in  exceptional 
instances  of  deep  ulceration.   Shrinkage  from  swallowing 


CICATRICIAL   CHANGES    IN   THE   PHARYNX.    .  327 

caustics  is  very  uncommon.  The  disturbances  may  be 
insignificant  in  case  of  moderate  deformity,  especially 
after  the  patient  has  become  accustomed  to  the  annoy- 
ance, or  they  may  be  extreme  and  of  vital  importance. 
Partial  or  total  shutting-ofFof  the  nasopharynx  gives  the 
voice  a  nasal  twang  and  enforces  mouth-breathing.  If 
suppuration  is  started,  it  persists  practically  incurable 
until  the  patency  of  the  postnasal  space  is  restored.  The 
ears  may  suffer  from  persistent  exudative  catarrh  or  sup- 
purative otitis.  Swallowing  is  made  difficult  by  any 
constriction  of  the  fauces  or  pharynx.  In  extreme  cases 
starvation  threatens.  Even  breathing  may  be  interfered 
with  to  an  extent  requiring  tracheotomy,  although  this  is 
very  exceptional  unless  the  cicatricial  shrinkage  involves 
the  larynx. 

Cicatricial  adhesions  cannot  be  prevented  during  the 
healing  of  ulcers  spreading  over  opposed  surfaces.  It  is, 
of  course,  worse  in  neglected  cases  on  account  of  the  ex- 
tent of  the  ulceration.  The  treatment  which  gives  the 
most  and  immediate  relief  is  the  division  of  any  folds  of 
mucous  membrane — for  instance,  the  pillars,  which  are 
made  tense  by  the  shrinkage  without  being  involved  in 
the  cicatrix.  When  space  can  be  gained  by  such  liber- 
ating incisions  in  healthy  tissue,  the  problem  is  an  easy 
one.  In  all  other  cases  treatment  is  tedious  and  often 
unsatisfactory.  The  division  of  adhering  surfaces  does 
not  prevent  their  ultimate  reunion.  Plastic  operations  are 
rarely  possible.  Partial  success  can  generally  be  obtained 
by  persistent  dilatation,  at  first  with  sponge-tents,  later 
on  by  means  of  hard-rubber  appliances,  sometimes  fast- 
ened to  the  teeth  according  to  dental  methods.  Fuller 
details  can  be  found  in  the  larger  treatises  on  diseases  of 
the  larynx. 


CHAPTER  XXIX. 

INFLUENCE  OF   NASAL  AND   PHARYNGEAL  AFFEC- 
TIONS UPON  OTHER  PARTS  OF  THE  ORGANISM. 

258.  Affections  of  the  nose  and  pharynx  are  not  rarely 
the  starting-point  of  disturbances  in  adjacent  organs,  or 
even  distant  parts  of  the  body.  The  majority  of  cases 
of  disease  of  the  middle  ear,  various  ocular  troubles, 
some  systemic  disturbances,  rare  instances  of  pyogenic 
affections  of  the  brain  or  its  membranes,  and  quite  often 
certain  functional  nervous  derangements,  can  be  traced 
etiologically  to  the  upper  air-passages.  The  routes 
through  which  nasal  or  pharyngeal  anomalies  may  in- 
volve other  organs  can  be  summarized  as — 

Extension  of  tumors; 

Extension  of  infection; 

Absorption  of  poisonous  products; 

Mechanical  influences  partly  exerted  through  the  blood 
and  lymph  circulation,  partly  through  impeded  breath- 
ing; 

Nervous  or  so-called  reflex  disturbances. 

In  some  of  the  cases  of  distant  disturbances  the  exact 
mode  of  origin  is  not  entirely  clear ;  in  some  others  nasal 
anomalies  exert  their  influence  through  several  of  the 
above-mentioned  routes.  For  most  purposes,  however, 
this  analysis  of  morbid  influences  suffices  for  an  under- 
standing of  the  pathogenesis. 

259.  Tumors  originating  in  the  nasal  passages  or  ac- 
cessory sinuses  may  invade  the  orbits  or  extend  through 
the  ethmoid  or  sphenoid  bone  into  the  cranial  cavity. 
This  is  true  as  well  of  malignant  carcinoma  and  sarcoma 
as  of  benign  but  encroaching  vascular  tumors  and  fibro- 
mata. There  is,  however,  not  a  large  number  of  such 
occurrences  on  record. 

328 


INFLUENCE    OF    NASAL   AND    PHARYNGEAL   AFFECTIONS.    329 

i?6o.  The  most  frequent  mode  in  which  nasal  afifections 
involve  other  organs  is  by  extension  of  infection.  This 
is  quite  rare  in  an  ordinary  uncomplicated  coryza,  rather 
more  likely  in  the  acute  rhinitis  of  influenza  or  measles, 
but  especially  so  when  a  purulent  process  occurs  in  nos- 
trils previously  stenotic.  I^ess  of  a  menace  to  the  ear, 
but  more  so  to  the  orbit  and  brain,  are  affections  of  the 
sinuses.  It  is  not  so  much  the  continued  chronic  condi- 
tion which  is  liable  to  extend  as  the  subacute  exacer- 
bation when  a  fresh  coryza  is  added.  The  organ  most 
likely  to  suffer  by  extension  of  nasopharyngeal  dis- 
ease is  the  ear,  in  the  form  of  purulent  otitis  or  serous 
catarrh.  The  ear  is  endangered  as  much  by  pharyngeal 
inflammations,  even  though  not  suppurative,  such  as 
tonsillitis,  pharyngitis,  or  diphtheria,  as  by  purulent 
processes  in  the  nose  itself  Pharyngeal  affections  are  all 
the  more  dangerous  to  the  ear  if  the  pharyngeal  or 
faucial  tonsils  are  permanently  enlarged.  Whether  the 
common  plastic  form  of  middle-ear  disease  (dry  catarrh) 
comes  under  the  head  of  infection  is  not  known.  Acute 
inflammatory  processes  in  the  nose  and  pharynx  are 
likely  to  extend  likewise  into  the  larynx  and  bronchial 
tubes,  and  if  the  disease  becomes  chronic  in  the  upper 
air-passages,  it  is  also  likely  to  persist  in  the  lower.  It 
is  not  positively  known,  however,  that  disease  of  the 
nose  may  directly  lead  to  involvement  of  the  lungs  them- 
selves, and  various  statements  to  this  effect  have  not  been 
adequately  supported  by  proof  An  occasional  complica- 
tion of  chronic  purulent  disease  of  the  nose  is  facial 
erysipelas,  sometimes  in  recurring  attacks. 

Affections  of  the  tear-passages  are,  as  a  rule,  due  to 
extension  of  nasal  disease.  This  is  true  of  hyper- 
trophic inflammation  causing  stricture,  as  well  as  of 
purulent  involvement  of  the  tear-sac.  Disease  of  the 
frontal  sinus  and  of  the  ethmoid  cells  may  invade  the 
orbit,  causing  either  a  circumscribed  abscess  or  a  diffused 
phlegmon.  The  eye  itself  may  suffer  in  the  course  of 
purulent  rhinitis  or  affections   of   the  sinuses.     Acute 


330    INFLUENCE   OF    NASAL   AND    PHARYNGEAL   AFFECTIONS. 

nasal  catarrh  is  often  accompanied  by  an  acute  conjunc- 
tivitis. In  what  way  the  deeper  structures  of  the  eye 
may  become  involved  is  not  clear,  but  the  coincidence 
of  eye  disease  with  purulent  nasal  affections  is  often 
striking,  and  their  relationship  apparently  confirmed  by 
the  results  of  treatment.  Tedious  forms  of  iritis,  exuda- 
tive choroiditis,  and  atypical  subacute  chorioretinitis  have 
been  seen  by  the  writer,  as  well  as  by  others  in  connec- 
tion with  purulent  sinus  aflfections  on  the  same  side. 
The  writer,  too,  has  seen  peripheral  palsies  of  the  ex- 
ternal ocular  muscles  occur  during  exacerbations  of 
purulent  nasal  conditions  (on  the  same  side),  and  cannot 
but  believe  that  they  were  dependent  upon  the  latter. 
How  the  infectious  material  is  transported  in  these  ob- 
scure instances  is  not  known.  In  rare  cases  on  record 
the  optic  nerves  have  suflfered  in  the  form  of  neuritis  or 
pressure  atrophy  in  consequence  of  the  upward  extension 
of  sphenoid  suppuration  beyond  its  confines.  Intra- 
cranial infections  in  the  form  of  meningitis  and  brain 
abscess  have  been  seen  as  the  consequence  of  purulent 
affections  of  the  frontal  and  sphenoid  sinuses  and  ethmoid 
cells,  very  rarely  in  acute,  mostly  in  chronic,  cases. 
This  extension  cannot  be  called  a  frequent  one,  although 
probably  many  such  instances  are  not  correctly  inter- 
preted by  the  general  practitioners. 

Sinus  suppuration  leads  in  rare  instances  to  pyemia  or 
metastatic  inflammations  in  distant  parts.  This  is  true 
also  of  ordinary  tonsillitis.  Endocarditis,  joint  aflfec- 
tions, visceral  abscesses,  have  been  observed  under  such 
circumstances.  The  relationship  of  tonsillitis  to  rheu- 
matism has  been  discussed  in  t  232.  To  what  extent 
tuberculosis  of  the  tonsils — faucial  or  pharyngeal,  cer- 
tainly not  a  rare  aflfection — endangers  the  system  by 
extension  is  at  present  an  open  question. 

261.  Suppurative  processes  in  the  nose  and  accessory 
cavities  may  undermine  the  health  by  the  absorption  of 
toxins.  The  systemic  poisoning  reveals  itself  in  some 
instances  by  a  loss  of  strength  and  appetite  and  increas- 


MECHANICAL    INFLUENCE.  331 

ing  anemia.  It  is  not  improbable  that  the  continued 
absorption  of  poisons  may  account  for  the  neurasthenia 
often  observed  in  such  patients.  The  swallowing  of 
pus  is  probably  also  not  wholly  indifferent,  as  the  puru- 
lent masses  are  not  digested  by  the  action  of  gastric  juice 
and  pass  through  the  stomach  with  their  load  of  patho- 
genic or  fermentative  bacteria.  There  may  be  some  re- 
lation between  the  dyspepsia  often  complained  of  and  the 
swallowing  of  nasal  secretion. 

Under  the  head  of  absorption  of  poisonous  products 
may  also  be  included  the  various  forms  of  toxic  palsies 
occurring  subsequent  to  diphtheria.  Statements  as  to 
the  possibility  of  such  degenerative  changes  following  a 
simple  tonsillitis  have  in  no  case  been  supported  by  a 
sufficiently  thorough  bacteriologic  examination  of  the 
throat  disease. 

26a.  A  mechanical  influence  upon  the  system  may 
result  from  nasal  stenosis  by  reason  of  the  increased 
positive  expiratory  and  negative  inspiratory  pressure 
behind  the  narrowed  region.  As  an  instance  of  this 
effect  Freudenthal  has  claimed  the  frequent  coexistence 
of  nasal  obstructive  lesions  with  hernia.  Mechanical, 
too,  is  the  production  of  chest  deformities  in  rickety 
children  in  consequence  of  blockage  by  postnasal  vege- 
tations. A  more  frequent  occurrence  is  the  influence 
exerted  by  obstructive,  together  with  acute  inflamma- 
tory, nasal  lesions  upon  the  circulation  in  adjacent  re- 
gions. Bilateral  nasal  obstruction,  especially  when  due 
to  the  enlarged  pharyngeal  tonsil,  is  often  accompanied 
by  mental  apathy,  inattention,  and  listlessness,  a  condi- 
tion which  has  been  termed  aprosexia.  It  is  probable 
that  this  depends  on  circulator^'  disturbances  within  the 
cranial  cavity.  This  may  be  also  the  origin  of  some  dull 
headaches  observed  under  such  circumstances.  Conges- 
tion of  the  conjunctiva  of  the  eyelids  is  a  very  common 
incident  in  nasal  disease,  and  in  its  turn  predisposes  to 
secondary  local  affections  like  .blepharitis.  Circulatory 
disturbances  are  often  revealed  by  a  dusky  hued  turges- 


332    INFLUENCE    OF    NASAL   AND    PHARYNGEAL   AFFECTIONS. 

cence  of  the  eyelids — for  instance,  in  hay  fever.  Con- 
gestion and  edema  of  the  Eustachian  orifices  are  common 
conditions  in  nasal  disease  favoring  morbid  involvement 
of  these  passages  and  of  the  middle  ear. 

A  variety  of  disturbances  may  occur  in  connection  with 
impeded  nasal  respiration,  such  as  restlessness  during 
sleep,  increasing  up  to  night-terror  and  nocturnal  incon- 
tinence of  urine.  These  disturbances  depend  probably 
on  temporarily  insufficient  aeration  of  the  blood.  They 
are  observed  often  in  children  with  adenoid  vegetations, 
but  occasionally,  too,  in  high  degrees  of  nasal  stenosis 
due  to  other  lesions.  Anemia  is  not  rarely  dependent  on 
insufficient  nasal  breathing  from  adenoids  or  extreme 
septum  deformities,  and  improves  after  a  successful 
operation.  In  what  manner  the  general  malnutrition 
so  often  found  in  children  with  adenoids  is  brought  about 
is  not  entirely  clear. 

363.  Certain  sequels  of  nasal  and  pharyngeal  affections 
which  have  attracted  much  attention  are  the  nervous  or 
so-called  reflex  disturbances.  The  term  ' '  reflex ' '  is  not 
an  appropriate  one,  for  in  physiology  it  signifies  the  re- 
action of  a  nerve  center  to  an  impulse  reaching  it  through 
a  sensory  nerve,  the  response  being  in  the  form  of  activity 
of  some  centrifugal  nerve.  Of  course,  this  definition  is 
inapplicable  to  sensory  disturbances,  and  not  quite  appro- 
priate to  most  of  the  motor  phenomena  which  come  under 
this  head,  as  these  are  but  exceptionally  the  exaggeration 
of  a  normal  reflex  act.  Most  of  the  so-called  motor  re- 
flexes are  really  due  to  a  state  of  morbid  excitability 
induced  in  the  nerve  centers  by  the  peripheral  stimulus. 
The  author,  hence,  prefers  to  call  these  nervous  dis- 
turbances (sensory,  motor,  or  vasomotor)  "neuroses  of 
peripheral  origin" — /.  ^.,  of  nasal,  ocular,  etc,  origin, 
as  the  case  may  be. 

The  dependence  of  a  neurosis  upon  a  suspected  periph- 
eral lesion  can  only  be  proved  definitely  by  a  successful 
therapeutic  test.  A  commonly  observed  coexistence  of 
peripheral  lesion  and  neurosis  may  suggest  a  relationship. 


NASAL       REFLEXES.  333 

This  suspicion  may  be  confirmed  by  a  time  relation — for 
instance,  when  the  nervous  disturbances  increase  when- 
ever the  nasal  symptoms  become  more  pronounced.  The 
etiologic  hypothesis  is  also  favored  when  the  nervous 
symptoms  are  one-sided  and  on  the  side  of  the  nasal 
affection.  But  a  definite  proof  is  only  furnished  when 
the  neurosis  ceases  promptly  after  the  elimination  of  the 
peripheral  lesion.  Of  course,  the  possibility  of  an  in- 
fluence by  mental  suggestion  must  be  taken  into  account 
in  the  case  of  transitory  nervous  phenomena.  The  etio- 
logic proof  is  all  the  more  positive,  however,  in  those 
cases  in  which  the  cure  has  been  an  incomplete  one,  and 
in  which  a  relapse  of  the  neurosis  coincides  with  the  re- 
turn of  the  peripheral  affection. 

Since  these  neuroses  occur  but  in  small  proportion  of 
patients  with  nasal  disease,  it  is  necessary  to  assume  that 
other  factors  besides  the  peripheral  lesion  are  requisite 
for  their  production.  We  must  infer  an  increased  sensi- 
tiveness or  diminished  resisting  power  of  the  nerve- 
centers.  The  nasal  lesions  may  have  existed  for  a  long 
time  without  nervous  disturbances,  the  latter  appearing 
only  after  other  predisposing  conditions  had  come  into 
play.  In  some  cases  this  nervous  instability  is  clearly 
suggested  by  the  patient's  previous  personal  or  family 
history,  as  a  hereditary  liability  to  functional  nervous 
disease  can  often  be  elicited.  In  other  cases  previous  en- 
feebling influences,  sedentary  habits,  and  want  of  out- 
door exercise,  long  interference  with  sleep,  anxiety, 
sometimes  pregnancy,  convalescence  from  infectious  dis- 
eases, and  especially  anemia  play  an  etiologic  role.  But 
neuroses  of  peripheral  origin  may  also  occur  in  persons 
of  apparently  good  health,  in  whom  we  must  assume  an 
instability  of  the  nervous  system  without  being  able  to 
prove  it.  These  disturbances  have  but  a  remote  con- 
nection with  hysteria.  They  may  occur  in  hysteric  sub- 
jects, but  are  not  particularly  frequently  observed  in 
them.  On  the  other  hand,  they  may  be  much  exaggerated 
and  diversified  by  the  coexistence  of  hysteria. 


334    INFLUENCE    OF    NASAL   AND    PHARYNGEAL   AFFECTIONS. 

Neuroses  of  nasal  origin  are  favored  by  existing  dis- 
turbances of  the  stomach  and  intestines.  Not  merely  are 
these  two  conditions  often  associated,  but  it  can  be  learned 
in  many  instances  that  aggravation  of  the  intestinal  con- 
dition increases  both  the  nasal  discomfort  and  the  nervous 
phenomena,  while  the  successful  management  of  dyspep- 
sia or  constipation  may  for  the  time  reduce,  or  even 
remove,  the  neurosis. 

Nasal  neuroses  may  be  brought  on  by  various  nasal 
lesions.  Of  the  sensory  neuroses,  especially  those  of  a 
relatively  constant  character,  the  larger  part  is  due  to 
affections  of  nasal  sinuses.  In  the  case  of  acute  severe 
sinuitis,  headaches  and  neuralgic  pains  are  so  constant  a 
phenomenon  that  they  must  be  considered  a  direct  symp- 
tom rather  than  a  superadded  Efeurosis.  With  suflficient 
intensity  of  sinus  inflammation  every  subject  will  get  the 
same  pains,  whether  he  be  neurotic  or  not.  But  in  the 
case  of  chronic  affections  the  condition  of  the  nervous 
system  determines  the  amount  and  extent  of  suffering. 
While  in  some  a  chronic  sinuitis  may  cause  no  pain  what- 
soever, others  of  a  more  neurasthenic  type  complain  at 
least  of  periodic  attacks,  sometimes  even  of  more  or  less 
constant  spells  of  neuralgic  pains.  An  important  deter- 
mining factor  is.  the  pressure  of  the  pus  in  the  sinus. 
With  retention  there  is  much  greater  probability  of  pain 
than  when  the  flow  through  the  natural  orifice  is  unim- 
peded. 

Most  motor  neuroses  and  some  sensory  disturbances, 
especially  those  of  periodic  type,  are  due  to  a  different 
form  of  nasal  disease.  They  are  observed  mainly  in  pa- 
tients with  nasal  irritability  associated  with  turgescence 
of  the  cavernous  tissue.  As  stated  in  1  86,  the  liability 
to  turgescence  of  the  nasal  lining  is  in  some  instances  due 
to  the  presence  of  irritating  lesions — viz.,  small  polypi, 
papillomata,  sharp-edged  crests  on  the  septum,  or  foci  of 
suppuration.  Quite  often  there  are  septum  deformities. 
In  such  cases  any  existing  reflex  nerv-ous  disturbances 
will  generally  cease  after  these  primary  lesions  have  been 


NEUROSES   OF   NASAL   ORIGIN.  335 

eliminated.  But  there  are  many  instances  in  which  nasal 
irritability  and  vascular  turgescence  are  observed  without 
an}'^  other  coexisting  intranasal  anomaly.  The  condition 
seems  to  be  the  result  of  previous  acute  nasal  inflam- 
mations in  persons  of  a  neurotic  disposition.  This  nasal 
irritability  without  coexisting  other  lesions  is  not  rarely 
the  starting-point  of  neuroses.  Their  occurrence  depends 
in  many  such  cases  on  the  periodic  turgescence  of  the 
cavernous  tissue,  and  if  this  be  thoroughly  destroyed,  the 
neurosis  will  cease.  Since  the  galvanocaustic  destruc- 
tion of  the  enlarged  cavernous  tissue  can  put  an  end  to  a 
neurosis,  even  without  the  removal  of  coexisting  irritating 
lesions,  Hack,  the  pioneer  in  this  field,  formulated  the 
theory  that  nasal  neuroses  depended  upon  the  turgescence 
of  enlarged  cavernous  tissue.  This  view  has  not  been 
upheld  in  its  entire  extent  by  subsequent  experience. 
But  it  is  nevertheless  true  that  neuroses  of  nasal  origin, 
especially  motor  neuroses  and  those  of  a  periodic  type, 
rarely  occur  except  in  connection  with  periodic  turges- 
cence of  the  venous  plexus.  Neither  diffuse  hypertrophy 
of  the  mucous  membrane  with  relative  contraction  of  the 
veins  nor  atrophic  processes  of  the  nasal  lining  lead  to 
neuroses  of  this  type.  It  is  sometimes  possible  to  induce 
experimentally  a  transient  attack  of  a  neurosis,  for  in- 
stance, headache  or  asthma  by  irritation  of  the  mucous 
membrane  with  a  probe  or  with  chemical  irritants.  It 
can  be  seen  in  such  cases  that  the  intranasal  turgescence 
precedes  the  nervous  disturbances. 

264.  The  various  forms  of  neuroses  of  nasal  origin  maj^ 
be  summarized  under  the  following  heads  : 

The  most  typical  reflex  is  sneezing,  sometimes  occur- 
ring in  fits  of  distressing  duration  and  accompanied  by 
one-sided,  later  on  even  by  bilateral,  vascular  occlusion 
with  serous  discharge.  The  occurrence  of  this  reflex 
varies  considerably  with  the  nervous  instability  of  the 
patient  at  different  times,  and  depends,  of  course,  on  the 
occasions  for  direct  provocation,  such  as  drafts,  dust, 
irritant  fumes,  sometimes  idiosyncratic  smells.     When  a 


336    INFLUENCE   OF   NASAL   AND    PHARYNGEAL   AFFECTIONS. 

distinct  morbid  lesion  can  be  found  as  the  starting-point 
of  the  irritation,  a  polypus  or  a  septum  crest  with  sharp 
edge,  sometimes  even  a  fissure  in  the  vestibule,  the  re- 
moval of  the  lesion  often  stops  the  attacks  permanently. 
In  other  instances  the  reflex  is  only  relieved,  but  not 
entirely  controlled,  until  the  overdeveloped  cavernous 
tissue  is  destroyed  by  one  or  more  thorough  applications 
of  the  galvanocaustic  burner.  Where  no  irritant  lesion 
can  be  found,  the  destruction  of  the  excessive  cavernous 
tissue  is  the  only  therapeutic  resource.  There  are,  how- 
ever, rare  instances  in  which  this  nasal  irritability  occurs 
without  much  accompanying  vascular  turgescence  and 
without  any  occlusion,  and  in  such  cases  no  local  meas- 
ures are  applicable.  The  only  way  of  benefiting  these 
patients  is  by  judicious  attention  to  the  nervous  system  or 
improved  climatic  environment. 

265.  Spasmodic  cough  is  rarely  due  to  nasal  lesions,  but 
is  not  infrequently  of  pharyngeal  origin.  It  has  been 
observed  in  connection  with  hypertrophies  in  the  poste- 
rior parts  of  the  nasal  passages,  especially,  however,  as  a 
neurosis  complicating  enlargement  of  lymphatic  tissue, 
either  of  the  pharyngeal  tonsil  or  of  follicles  on  the  poste- 
rior walls.  Sometimes  relatively  small,  though  hyper- 
trophied,  faucial  tonsils,  especially  when  chronically  in- 
flamed, are  the  starting-point  of  coughing  spells,  as  can 
be  shown  by  irritation  with  the  probe.  In  most  of  these 
instances,  but  by  no  means  in  all,  the  cough  is,  at  least 
in  part,  accounted  for  by  a  complicating  inflammation  in 
the  larynx  or  bronchial  tubes.  In  others  the  cough  is 
purely  a  reflex  from  morbid  spots  above  the  larynx. 
Proper  local,  especially  surgical,  measures  can  remove 
the  cough  permanently. 

266.  Asthma  is  in  certain  instances  a  neurosis  of  nasal 
origin.  The  frequency  of  this  etiologic  relationship  has 
been  much  overrated  by  some  rhinologists  since  the 
days  of  Hack,  but  underrated  or  too  often  ignored  by 
writers  on  internal  medicine.  It  must  be  clearly  under- 
stood that  asthma  depends  often  on  pulmonar}'  lesions 


ASTHMA.  337 

(emphysema),  cardiac  or  renal  disease,  and  is  in  no  way 
connected  with  the  nose.  But  it  is  equally  positive  that 
there  are  instances  of  typical  asthmatic  attacks  which 
result  from  nasal  anomalies  and  are  permanently  cured 
by  their  removal.  The  most  frequent  and  the  most 
definite  instances  of  this  kind  are  those  due  to  nasal 
polypi.  Here  a  complete  removal  of  the  growth  stops 
the  attacks,  while  a  return  of  the  polypi  brings  back  the 
spells  of  asthma.  In  other  cases  the  cause  is  suppurative 
disease,  sometimes  of  the  maxillary  sinus,  more  often  of 
the  ethmoid  cells.  These  affections  are  not  cured  so 
quickly,  and  especially  ethmoid  disease  may  prove  very 
rebellious,  with  corresponding  persistence  of  the  asthma. 
Repeatedly  I  have  seen  asthma  dependent  on  spurs  on 
the  septum,  especially  those  which  touch  the  middle  tur- 
binal  toward  the  rear.  Occasionally  no  structural  nasal 
lesion  can  be  found  except  enlargement  of  the  cavernous 
tissue.  A  cure  in  such  instances  depends  on  the  thor- 
oughness with  which  the  enlarged  vascular  tissue  is 
destroyed.  The  writer  has  observed  a  striking  instance 
of  this  kind  in  the  person  of  a  physician,  a  sufferer 
from  periodic  asthma  since  childhood,  who  submitted  to 
a  galvanocaustic  burning  in  1883.  The  first  operation 
gave  him  decided  relief  as  to  the  frequency  and  average 
intensity  of  the  spells.  But  a  continuation  of  galvano- 
caustic treatment  did  not  stop  the  attacks  completely  for 
a  long  while.  Fully  impressed  by  the  views  stated  at 
that  time  by  Hack,  the  patient  submitted  in  the  course 
of  a  year  to  fourteen  caustic  operations,  until  the  sub- 
jective feeling  of  periodic  nasal  turgescence  had  ceased 
completely,  even  on  exposure,  to  dust  and  other  irritations. 
Since  that  time,  a  period  of  over  fifteen  years,  the  gentle- 
man has  been  entirely  free  from  asthma. 

Hay  fever  is  accompanied  very  commonly  by  asthmatic 
breathing.  Properly  applied  surgical  measures  often 
relieve  this  asthmatic  feature  markedly,  even  if  they  do 
not  prevent  hay  fever. 

The  diagnosis  of  the  nasal  origin  of  asthma  cannot 
22 


338    INFLUENCE   OF   NASAL   AND    PHARYNGEAL   AFFECTIONS. 

always  be  made  with  certainty.  It  is  probable  when 
nasal  symptoms  like  occlusion — and  less  often  sneezing 
fits — directly  precede  the  asthmatic  attack.  It  is  made 
positive  when  the  patient  can  check  the  spell  by  using 
cocain  or  suprarenal  solution  in  the  nose  at  the  beginning 
of  the  attack.  But  failure  of  this  test  does  not  disprove  a 
nasal  origin.  There  are,  indeed,  instances  in  which  the 
nasal  symptoms  are  scarcely  noticed  by  the  patient.  On 
the  other  hand,  the  rhiuologist  will  meet  occasionally 
with  therapeutic  failures  where  there  are  remediable 
nasal  lesions,  especially  in  cases  of  long  duration.  These 
cases,  probably  at  first  a  purely  nasal  neurosis,  have 
become  complicated  in  the  course  of  time  by  eitiier 
secondary  changes  in  the  nervous  system  or  peripheral 
lesions  like  emphysema,  which  remain  after  the  nasal 
anomaly  is  removed. 

267.  The  characteristic  symptom  of  the  asthmatic 
attack  is  difficult  inspiration.  This  is  attended  by  a 
wheezing  sound,  audible  even  at  a  short  distance.  There 
is  a  feeling  of  intense  oppression  over  the  chest.  Ex- 
piration, though  not  normal,  is  less  labored.  If  not 
aborted,  the  attack  usually  lasts  hours.  As  a  rule,  the 
patient  has  normal  breathing  between  the  asthmatic  at- 
tacks. In  severe  cases  there  may  be  labored  breathing 
continuously  for  long  periods  of  time,  intensified,  how- 
ever, to  an  agonizing  extent  during  the  t^^pical  attacks. 
The  spells  recur  in  a  very  irregular  manner.  For  a  time 
they  may  return  every  night.  But,  as  a  rule,  asthma  of 
nasal  origin  does  not  occur  so  frequently  or  persistently. 
Under  favorable  climatic  influences  or  change  of  residence 
it  may  stay  away  indefinitely.  A  mere  change  from  one 
street  to  another  may  have  an  influence.  On  the  other 
hand,  dust  and  irritating  gases  or  '*  idiosyncratic"  smells 
may  bring  on  an  attack. 

The  conditions  upon  which  the  impediment  to  breath- 
ing depends  have  not  been  definitely  demonstrated. 
Tonic  contraction  of  the  diaphragm,  spasm  of  the  un- 
striated  muscular  fibers  in  the  bronchial  walls,  conges- 


NAUSEA — VOMITING.  339 

tioti  of  the  mucous  membrane  in  the  smaller  bronchial 
tubes,  have  been  accused  by  different  writers  as  the 
lesions  underlying  the  attack.  The  writer  is  inclined  to 
believe  that  in  severe  attacks  edema  of  the  bronchial 
tubes  probably  plays  a  role,  since  an  edematous  condition 
of  the  nasal  mucous  membrane  can  sometimes  be  demon- 
strated in  such  patients. 

The  treatment  of  asthma  will  be  discussed  with  refer- 
ence to  the  cases  of  nasal  origin  only.  Where  no  de- 
monstrable intranasal  lesions  can  be  found,  and  where 
close  questioning  elicits  no  history  of  nasal  turgescence, 
the  case  does  not  come  under  the  care  of  the  rhinologist. 
In  doubtful  instances  the  patient  may  make  the  attempt 
to  abort  the  attack  at  the  beginning  by  inserting  pledgets 
of  cotton  with  5  per  cent,  cocain  solution,  with  or  with- 
out the  addition  of  suprarenal  extract.  For  permanent 
purposes  cocain  should  never  be  given. 

For  curative  purposes  the  nasal  lesion  suspected  as  the 
starting-point  of  asthma  should  be  removed  surgically. 
Pronounced  septum  deflection  should  be  straightened. 
Lateral  crests,  especially  those  which  touch  the  external 
wall,  should  be  cut  off  by  the  use  of  the  saw,  trephine, 
or  spoke-shave.  Polypi  should  be  removed  and  suppura- 
tive foci  properly  treated.  Where  excessive  cavernous 
tissue  plays  a  role,  it  must  be  destroyed  completely  by 
the  galvanocautery.  Temporary  relief  may  be  obtained 
by  inhaling  fumes  of  burning  stramonium  leaves,  espe- 
cially in  the  form  of  the  so-called  Kidder's  pastilles  (or 
Schiffman's  powder).  Until  the  cure  is  completed  a 
change  of  residence  may  prove  palliative.  A  trip  to  the 
mountains  gives  immediate  relief,  sometimes  lasting  for 
quite  a  while. 

268.  Nausea  and  efforts  at  vomiting  are  occasionally 
caused  by  pharyngeal  disease,  especially  b)^  hypertrophy 
and  chronic  inflammation  of  the  lingual  tonsil.  These 
disturbances  are  common,  too,  in  connection  with  the 
diffuse  hypertrophic  pharyngitis  seen  in  smokers  and 
drinkers.     In  the  latter  cases  the  irritated  condition  of 


340   INFLUENXE    OF    NASAL   AND    PHARYNGEAL   AFFECTIONS. 

the  lining  of  the  stomach  is  probably  also  a  determin- 
ing condition.  Nevertheless,  local  pharyngeal  treatment 
may  prove  satisfactory,  but  bad  habits  must,  of  course, 
be  corrected. 

Cardiac  disturbances,  sometimes  irregularities  and  inter- 
mittence  of  the  pulse,  more  often  palpitation  (tachycar- 
dia), have  been  observed  as  the  result  of  hypertrophies 
of  the  posterior  ends  of  the  turbinals,  and  have  been 
checked  by  proper  local  treatment. 

269.  There  are  on  record  a  few  observations  of  exoph- 
thalmic goiter  (Graves'  or  Basedow's  disease)  which  are 
said  to  have  been  cured  by  the  cauterization  of  intra- 
nasal cavernous  tissue.  These  cases  were  all  reported 
when  the  first  enthusiasm  concerning  nasal  reflexes  pre- 
vailed, and  none  have  been  described  since  that  time. 

Epileptic  convulsions  have  been  referred  to  a  nasal  origin 
in  a  small  number  of  instances.  Many  of  these  cases 
have  been  reported  after  too  short  a  period  of  time  to  be 
considered  as  satisfactory  demonstrations,  yet  there  are  a 
few  on  record  in  which  a  nasal  origin  seems  fairly  well 
established  by  the  permanent  cessation  of  the  attacks 
after  nasal  treatment.  Reflex  epileptoid  spasm  is  prob- 
ably a  very  rare,  though  possible,  neurosis  of  nasal 
origin.  The  writer  has  seen  an  instance  of  petit  mal 
with  laryngeal  spasm  in  an  infant,  apparently  due  to  a 
chronic  pharyngitis  which  ceased  permanently  after  the 
successful  treatment  of  the  inflammation  by  nitrate  of 
silver. 

Chorea  has  also  been  described  as  an  occasional  neurosis 
of  nasal  or  pharyngeal  origin.  The  evidence,  however, 
is  not  satisfactory.  It  is  entirely  improbable  that  a 
general  chorea  should  be  started  in  this  manner,  but  it 
is  not  unlikely  that  choreiform  twitchings  of  the  eyelids 
and  facial  muscles  may  in  some  cases  depend  upon  nasal 
or  -phsiTyngeal  irritation.  While  such  cases  may  be 
benefited  gradually  by  proper  local  treatment,  the  thera- 
peutic results  are,  as  a  rule,  not  sufficiently  prompt  to 
prove  the  relationship. 


NEUROSES   OF   NASAL  ORIGIN.  34 1 

There  are  on  record  a  few  instances  of  clonic  spasm 
of  the  facial  nerve  cured  by  intranasal  cauterization. 

270.  Numerous  sensory  disturbances  have  been  de- 
scribed as  reflex  neuroses  of  nasal  origin.  In  the  case  of 
severe  and  constant  headache  and  neuralgic  pains  accom- 
panying the  inflammatory  lesions,  especially  acute  sup- 
puration of  the  sinuses,  it  seems  more  logical  to  classify 
the  pain  as  a  symptom  due  to  radiation  of  the  sensation 
rather  than  as  a  complicating  neurosis.  Periodic  attacks, 
however,  of  either  headache  or  of  neuralgic  pains,  can 
be  more  properly  interpreted  as  neuroses  of  nasal  origin. 
In  the  first  publications  on  this  topic,  fifteen  to  eighteen 
years  ago,  many  instances  of  such  pains  were  referred  to 
turgescence  of  the  nasal  cavernous  tissue  and  apparently 
cured  by  its  destruction.  More  recent  experience,  how- 
ever, has  taught  that,  as  a  rule,  demonstrable  and  struc- 
tural lesions  are  present  in  these  cases — viz.,  sinus  dis- 
ease, polypi,  or  other  tumors  or  septum  crests.  Thorough 
search  for  intranasal  lesions  and  judicious  treatment  lead 
to  many  satisfactory  results  in  obscure  forms  of  headaches 
and  neuralgic  pains.  The  writer's  experience  has  shown 
him  that  in  some  such  instances  the  cause  may  be  found 
in  suppuration  at  the  roof  of  the  pharynx,  as  well  as  in 
the  purely  nasal  lesions. 

A  form  of  sensory  disturbances,  very  common  in  nasal 
disease,  especially  in  pronounced  hypertrophic  rhinitis 
and  septum  deformities,  is  asthenopia,  the  inability  to  use 
the  eyes  without  itching,  burning,  smarting,  and  other 
uncomfortable  or  painful  sensations.  It  is  doubtful 
whether  this  is  a  purely  nervous  influence  or  whether 
it  does  not  depend  in  part  upon  a  circulatory  disturbance 
within  the  eyes.  In  well-selected  cases  the  therapeutic 
results  of  nasal  treatment  are  very  satisfactory. 

A  few  extremists  have  occasionally  reported  neuras- 
thenia as  a  nasal  reflex.  This  cannot  but  be  considered  a 
misinterpretation.  Neurasthenia  can  undoubtedly  be 
engendered  in  the  long  run  in  predisposed  subjects  by 
long-continued  suppuration  of  the  nasal  accessory  cavi- 


342    INFLUENCE   OF    NASAL   AND    PHARYNGEAL   AFFECTIONS, 

ties.  But  this  is  a  toxic  rather  than  a  nervous  influence. 
A  neurasthenic  patient  can,  moreover,  be  made  worse  by 
any  frequently  recurring  headache  due  to  nasal  disease. 
In  such  instances  nasal  treatment  may  give  relief  by 
abolishing  the  pain  and  permitting  the  depressed  nervous 
system  to  recover,  but  the  alleged  direct  dependence  of 
neurasthenia  upon  peripheral  irritation  is  not  in  accord 
with  any  judicious  views  regarding  the  nature  of  neuras- 
thenia. 

Although  a  few  reliable  cures  of  asthma  by  the  removal  of 
nasal  polypi  had  previously  been  reported,  the  subject  of  "  nasal 
reflexes"  received  but  little  attention  until  Hack  proved  its  im- 
portance. In  numerous  publications  from  1881  up  to  his  death  in 
1887  he  showed  the  frequency  of  a  variety  of  neuroses  of  nasal 
origin.  The  fullest  details  are  found  in  his  work,  Ueber  die  op. 
Radicalbehandlung  bestimmter  Formen  von  Migraine,  Asthma, 
Heufieber,  etc. ,  W.  Hack,  1884.  At  the  same  time  Roe  and  Dal\-  in 
this  country  suggested  the  nasal  origin  of  hay  fever.  A  flood  of 
publications  followed,  many  of  them  of  uncritical  character.  Some 
of  the  earlier  crude  ideas  and  exaggerations  have  since  been  re- 
futed, while  the  better-founded  claims  have  been  extensively 
confirmed.  The  attention  given  to  nasal  reflexes  led  also  to  the 
recognition  of  the  influence  of  nasal  and  pharj'ngeal  diseases 
upon  the  general  health  through  other  routes  besides  the  nervous 
system. 


M 


nlu  (nginad)  "^a'tHnohaiH— 

s  ..mA 

■f/T— .^  .oi'H 
I'ira  b«JD  lomlni 
1  .rh  sH)  ;  (cnnoo 

liUuD  biwj 
I  ^ajs  vi9}/>i3i>om  Ix»3ibIo9 

(.(inn     :',ii(n7 


PLATE    I. 

Fig.  I. — Perforating  (benign)  ulcer  of  the  nasal  septum,  its  edge  almost 
entirely  healed. 

Fig.  2. — Syphilitic  ulceration  of  the  nasal  septum,  extending  toward  the 
rear  further  than  the  view  ;  the  lower  edge  of  the  ulcer  is  covered  with  crusts  ; 
pus  and  crusts  above  the  ulcer  on  the  left  side  (reversed)  ;  a  broad  adhesion 
between  the  right  middle  turbinal  and  the  septum. 

Fig.  3. — Turgescence  of  the  cavernous  tissue  of  the  rear  ends  of  the  (left) 
inferior  and  middle  turbinals,  occluding  a  nasal  passage  otherwise  structurally 
normal  ;  the  right  side  is  represented  after  all  engorgement  has  been  removed 
by  a  cocain  spray. 

Fig.  4. — Hypertrophy  of  the  mucous  membrane  of  the  inferior  turbinals  as 
seen  in  the  postnasal  mirror.  On  the  right  side  of  the  septum  there  is  a  poly- 
poid cushion  of  hypertrophied  mucous  membrane  ;  the  pharyngeal  tonsil  is 
enlarged  moderately  and  is  not  undergoing  any  marked  involution.  (From  a 
young  man.) 


Plate 


FiG.    1. 


Fic.2. 


Fio.  ^. 


Fio.  H. 


BOOK  11. 
DISEASES  OF  THE  EAR. 


BOOK  IL 
DISEASES  OF  THE  EAR. 


CHAPTER   XXX. 
ANATOMY   AND   PHYSIOLOGY  OF   THE   EAR. 

371.   General  Anatomy  and   Development. — The 

auditory  organ  is  divided  into  the  interior,  middle,  and 
external  ear.  The  interior  ear  consists  of  the  termina- 
tions of  the  auditory  nerve  in  the  interior  of  chambers 
hollowed  out  in  the  depth  of  the  petrous  bone.  This, 
the  apparatus  for  the  perception  of  sound,  is  the  first  part 
of  the  ear  developed  in  the  embryo  and  the  only  part 
found  in  the  lower  vertebrates,  especially  the  fishes.  It 
develops  at  the  side  of  the  hind-brain  vesicle  in  the  form 
of  a  pit  in  the  epiblast,  which,  as  it  sinks  in  deeper, 
changes  into  a  vesicle  detached  from  the  surface.  The 
auditory  nerve,  growing  out  from  the  brain,  enters  this 
vesicle.  The  latter  elongates  and  divides  into  two  por- 
tions— the  upper  becoming  the  utriculus,  the  lower,  the 
sacculus.  From  the  upper  extrude  hollow  ridges  which 
change  into  the  semicircular  canals.  The  lower  cavity 
sends  forth  a  tubular  extension,  the  cochlea.  This  tube 
coils  in  a  spiral  manner  in  higher  animals,  reaching  2J 
turns  in  man.  The  semicircular  canals,  of  which  it  is 
doubtful  whether  they  serve  for  hearing,  exist  in  all  ver- 
tebrates, although  the  lowest  fishes  have  but  two.  The 
cochlea,  the  organ  of  sound  perception,  is  developed 
progressively  in  the  animal  scale  beyond  fishes.  Semi- 
circular canals  and  cochlea  constitute  the  labyrinth  con- 
tained in  tunneled-out  spaces  in  the  petrous  bone.     In 

Mb 


346  ANATOMY    AND    PHYSIOLOGY    OF   THE    EAR. 

the  course  of  embryonic  growth  these  epithelial  structures 
become  surrounded'  by  a  cartilaginous  capsule,  which 
ultimately  changes  into  a  thin  compact  bony  shell  of 
characteristic  shape  imbedded  in  the  cancellated  bony 
tissue  of  the  petrous  pyramid.  Between  the  cap.sule  and 
its  epithelial  contents  a  layer  of  gelatinous  embryonic 
(mesodermal)  tissue  furnishes  the  membranous  tunics  of 
the  labyrinth,  while  its  partial  rarefaction  leads  to  the 
formation  of  the  subsequent  lymph-spaces  filled  with 
fluid.  The  acoustic  communication  between  labyrinth 
and  surrounding  medium  takes  place  through  a  mem- 
branous window.  It  is  remarkable  how  very  little  the 
interior  ear — especially  the  semicircular  canals — varies 
with  the  size  of  the  animal. 

A  middle  ear  or  drum  cavity  is  found  in  nearly  all  ver- 
tebrates living  on  land.  It  consists  of  an  air-space  within 
bony  walls  separated  from  the  external  air  by  the  thin 
tympanic  membrane.  The  sound  vibrations  taken  up  by 
this  membrane  are  conveyed  by  a  rod  of  bone  or  a  set  of 
ossicles  to  the  membrane  of  the  labyrinth.  The  drum 
cavity  communicates  with  the  atmosphere  through  the 
Eustachian  tube,  reaching  from  tympanum  to  pharynx. 
The  drum  cavity  is  formed  by  a  recess  on  the  external 
surface  of  the  petrous  part  of  the  temporal  bone,  which  is 
completed  as  a  closed  cavity  by  articulation  with  the 
squamous  and  tympanic  portions  of  that  bone.  It  de- 
velops as  a  recess  from  the  upper  part  of  the  first  visceral 
cleft  of  the  embryo  at  the  same  time  with  the  Eustachian 
passage,  which  latter  from  the  start  communicates  with 
the  pharynx.  During  its  formation  the  tympanic  cavity 
is  filled  with  gelatinous  embryonal  tissue.  The  ossicles 
of  the  middle  ear  develop  outside  and  underneath  the 
embryonic  drum  cavity,  as  shown  in  Fig.  85.  The  ham- 
mer and  anvil  and  the  bony  frame  of  the  drumhead — 
the  annulus  tympanicus — are  derived  from  the  cartilage 
formed  in  the  first  visceral  arch,  while  that  of  the  second 
visceral  arch  furnishes  the  material  for  the  stapes.  These 
ossicles  thus  started  outside  of  the  skull  gradually  enter 


SURGICAL  ANATOMY. 


347 


the  tympanic  cavity  from  underneath  as  its  embryonal 
connective-tissue  contents  become  absorbed. 

The  external  ear  consists  of  the  conduit  tube  lead- 
ing to  the  drumhead — the  external  auditory  meatus. 
The  bony  part  of  this  passage  forms  only  after  birth.  In 
the  new-born  the  external  ear  consists  but  of  a  cartilagin- 
ous tube  (the  external  meatus)  and  its  expansion  in  the 
form  of  the  auricle.     In  lower  mammals  the  auricle  is 


Fig.  85. — Head  and  neck  of  a  human  embryo  of  eighteen  weeks.  The  vis- 
ceral skeleton  exposed  by  dissection  (Kolliker).  The  lower  jaw  is  displaced 
forward  in  order  to  show  Meckel's  cartilage,  which  can  be  followed  up  to  the 
malleus.  The  drumhead  has  been  removed,  and  the  annulus  tympanicus  is 
exposed  to  view  :  h.  a,  Malleus ;  M.  k,  Meckel's  cartilage ;  u.  k,  lower  jaw ; 
am,  anvil ;  st,  stapes  ;  f>r,  annulus  tympanicus  ;  grf,  styloid  process. 

practically  a  segment  of  a  funnel  for  catching  sound.  In 
man  and  the  higher  apes  this  function  is  lessened  by  rea- 
son of  its  less  favorable  shape. 

272.  Surgical  Anatomy. — The  auricle  is  made  up  of 
a  slightly  curved  plate  of  reticulated  cartilage,  convex  on 
its  inner  side,  its  outer  surface  being  convoluted  by  the 
ridges  and  furrows  visible  externally.  The  most  periph- 
eral posterior  ridge  is  the  helix.     Inward  from  it  and  ap- 


348  ANATOMY   AND    PHYSIOLOGY    OF   THE    EAR. 

proximately  parallel  with  it  is  the  antihelix.  The  pro- 
jection in  front  which  represents  the  outer  end  of  the 
cartilaginous  meatus  is  the  tragus,  and  opposite  to  it  is 
the  antitragus.  The  expansion  of  the  meatus  between 
tragus  and  antitragus  is  termed  the  concha.  The  cartil- 
age is  covered  by  a  perichondral  membrane.  In  the 
pendant  lobule  of  the  ear  there  is  no  cartilage,  the  space 
between  the  two  layers  of  the  skin  being  filled  with  fat. 
The  skin  is  more  adherent  on  the  concave  side  of  the 
auricle  than  on  the  convex  surface.  It  contains  numerous 
sebaceous  glands,  and  at  the  entrance  of  the  auricle  are 
more  or  less  fine  or — in  elderly  men — coarse  hairs.  Be- 
tween the  cartilaginous  ridges  there  are  several  small 
strands  of  muscular  fibers  of  no  significance.  The  flat 
muscles  which  move  the  auricle  in  animals  are,  with  rare 
exceptions,  not  under  the  influence  of  the  will  in  man. 
They  radiate  from  the  junction  of  auricle  and  meatus 
upward  and  backward  and  insert  themselves  partly  into 
the  adjoining  bony  surfaces  and  partly  into  the  fasciae. 
Underneath  these  muscles  the  fascia  surrounds  the  junc- 
tion of  auricle  and  meatus.  The  principal  anchorage  of 
the  auricle  is,  however,  maintained  by  the  cartilaginous 
meatus — the  inward  prolongation  of  the  auricular  cartil- 
age. 

273*  l^he  external  auditory  meatus  consists  of  a  car- 
tilaginous tube  set  into  a  bony,  funnel-shaped  conduit 
(Fig.  86).  The  entire  passage  is  lined  by  thin  skin,  the 
deeper  layer  of  which  serves  as  periosteum.  The  car- 
tilaginous portion  is  not  a  complete  tube,  but  a  thick, 
tapering  gutter  open  at  the  upper  and  posterior  side, 
which  gap  widens  inwardly  so  that  the  cartilage  tapers  at 
its  inner  end  with  a  blunt  apex  at  the  anterior  side.  The 
gap  is  closed  by  connective  tissue,  which  becomes  con- 
tinuous with  the  deeper  layer  of  the  skin  and  the 
periosteum  of  the  bony  part  of  the  channel.  The  car- 
tilaginous tube  is  broken  into  three  fragments  of  nearly 
equal  length  by  two  transverse  gaps  (incisurse  Santorini), 
across  which    there   is   a   membranous  junction.     This 


EXTERNAL   AUDITORY    MEATUS. 


349 


segmentation  permits  a  moderate  displacement  when  the 
auricle  is  pulled  upward  and  backward,  and  when  the 
articulation  of  the  lower  jaw  presses  against  the  cartilage 
on  closing  the  mouth.  The  cartilaginous  portion  is 
about  one-third  the  total  length  of  the  meatus.  It  can  be 
readily  separated  from  the  bony  canal  by  dissection,  which 
hence  permits  in  the  living  a  close  approach  to  the  drum- 
head. 

In  the  bony  canal  we  can  distinguish  four  walls  con- 
tinuous with  one  another.     The  upper  wall  is  formed  by 


Fig.  86. — Horizontal  section  through  the  external  meatus ;  left  ear :  C, 
Concha  ;  fr,  tragus  ;  i,  junction  of  cartilaginous  and  bony  meatus  ;  m,  mastoid 
process;  V,  anterior  wall  of  meatus  ;  S,  sinus-like  pouch  adjoining  the  drum- 
head; /,  membrana  tympani  ;    T,  tympanic  cavity  (Politzer). 

the  squamous  portion  of  the  temporal  bone.  This  con- 
sists of  two  firm  plates,  of  which  the  upper  is  the  inner 
surface  of  the  cranial  cavity  and  forms  in  part  the  roof  of 
the  tympanic  cavity.  The  lower  plate  separated  from 
the  upper  by  a  variable  thickness — up  to  8  mm. — of  can- 
cellated bone  extends  up  to  the  bony  frame,  across  which 
the  drumhead  is  stretched  external  to  the  drum  cavity. 
The  posterior  wall  separates  the  meatus  from  the  cells 
and  the  antrum  of  the  mastoid  process.  Superior  and 
posterior  walls  present  a  slight  concavity.     The  inferior 


350       ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 

wall  is  moderately  thick  'and  compact.  The  anterior 
wall,  a  thin  plate  of  bone,  separates  the  meatus  from 
the  articulation  of  the  jaw  with  the  glenoid  cavity 
(Figs.  87  and  88).  The  anterior  and,  more  so,  the 
inferior  wall  are  distinctly  convex.  The  lower  wall,  in- 
deed, descends  next  to  the  drumhead  to  such  an  extent 


Fig.  87. — Left  temporal  bone  (adult) :  frontal  section  through  bony  meatus  and 
tympanic  cavity ;  posterior  half  (Zuckerkandl). 


Fig.  88. — Left  temporal  bone  at  birth.  In  the  infantile  bone  the  squamous 
plate  is  nearly  vertical,  the  petrososquamous  fissure  is  still  open,  and  the  attic 
is  more  developed  than  the  rest  of  the  tympanic  cavity  (Zuckerkandl). 

that  a  dilatation  of  the  meatus,  called  the  sinus,  is  formed, 
in  which  foreign  bodies  may  lodge. 

In  the  thin  skin  lining  the  meatus  the  sweat-glands  are 
slightly  modified  and  yield  a  thick,  oily  secretion,  the 
ear-wax  or  cerumen.  These  glands,  the  orifices  of  which 
can  be  seen  by  the  naked  eye,  extend  throughout  the 
cartilaginous  portion,  but  in  the  bony  part  occupy  only  a 
narrow  sector  at  the  upper  posterior  wall,  reaching  nearly 
to  the  drumhead. 


EXTERNAL   AUDITORY    MEATUS. 


351 


The  meatus  is  approximately  elliptic  in  cross-section, 
with  its  long  axis  oblique  (pointing  upward  and  forward). 
About  8  to  10  mm.  in  average  diameter,  it  narrows  at  the 
point  of  greatest  convexity 
of  the  lower  wall  near  the 
drumhead, — sometimes  to 
about  5  mm.  (transversely), — 
but  dilates  again  before  it 
reaches  the  membrana  tym- 
pani.  Along  its  length  it  is 
slightly  curved,  with  con- 
vexity upward  and  backward. 
This  curve  is  nearly  obliter- 
ated by  forcibly  pulling  the 
auricle  upward  and  back- 
ward. The  average  length 
is  about  24  mm.,  but  the 
anterior  and  inferior  walls 
exceed  the  posterior  and  su- 
perior walls  by  about  5  to  6  mm.  in  length,  so  that  the 
plane  of  the  drumhead  is  quite  oblique. 

374.  The  anatomy  of  the  meatus  differs  considerably 
at  birth  from  its  fully  developed  condition.  The  bony 
meatus  is  so  flattened  from  above  downward  that  there  is 
scarcely  any  caliber.  There  is  no  bony  meatus  at  the 
time  of  birth.  The  obliquity  of  the  drumhead  is  much 
greater  than  later  on.     Indeed,  the  membrane  is  almost 


Fig.  89. — Left  temporal  bone  ; 
horizontal  section  through  the  bony 
meatus;  upper  half  (Zuckerkandl). 


Fig.  90. — External  aspect  of  the  annulus  tympanicus ;  left  ear  at  birth  :  «> 
tuberculum  tympanicum  anterior;/,  tuberculum  tympanicum  posterior  (Zucker- 
kandl). 


horizontal  and  nearly  at  the  base  of  the  skull.  Dissection 
shows  that  at  birth  the  membrana  tympani  is  attached  to 
a  bony  frame  in  the  form  of  an  incomplete  ring, — the 


352 


ANATOMY  AND   PHYSIOLOGY   OF   THE   EAR. 


annulus  tympanicus, — of  which  an  upper  segment  is 
wanting  (Fig.  90).  This  bony  ring  is  grooved  on 
its  interior,  and  into  this  groove  the  membrane  is 
set.  In  the  new-born  the  squamous  portion  of  the 
temporal  bone  is  merely  a  vertical  plate,  to  the  lower 
edge  of  which  the  annulus  is  attached  (Fig.  91).  The 
mastoid  process  is  as  yet  undeveloped,  not  projecting  and 
not  cancellated.  The  tympanic  bone  (annulus)  now 
grows  until  it  constitutes  a  bony  gutter,  which  ultimately 
forms  the  anterior,  inferior,  and   posterior  walls  of  the 


Fig,  91. — Left  temporal  bone  of  the  new-born  :  S,  Squamous  portion  ;  «,  its 
lower  part  with  malar  ridge ;  a,  annulus  tympanicus ;  w,  n,  suture  between 
squamous  portion  and  mastoid  extending  to  /,  the  stylomastoid  foramen  ;  o, 
oval  window  ;  r,  round  window  (Politzer). 

meatus.  The  posterior  wall  coalesces  with  the  develop- 
ing mastoid  process.  The  upper  wall  of  the  meatus  is 
gradually  formed  by  the  growth  of  the  squamous  portion 
in  the  form  of  the  horizontal  plate  extending  inward 
from  the  outer  surface  of  the  skull,  and  in  the  course  of 
this  growth  the  horizontal  position  of  the  drumhead 
changes  ultimately  to  its  more  erect  plane.  About  the 
fourth  year  of  life  the  ultimate  shape  of  the  bony  meatus 
is  perfected,  and  its  growth  now  continues  at  a  diminished 
rate  until  a  few  years  after  puberty. 


TYMPANIC    CAVITY. 


353 


275.  The  auricle  is  supplied  by  a  number  of  small 
arterial  twigs  radiating  toward  it  from  the  arteries  in  the 
neighborhood.  Some  of  these  twigs  enter  the  meatus. 
The  venous  supply  is  similar.  The  muscles  of  the  ex- 
ternal ear  are  supplied  by  the  facial  nerve.  The  sensory 
nerves  are  twigs  from  the  auriculotemporal  branch  of  the 
fifth  nerve  and  the  auricularis  magnus  of  the  cervical 


Fig.  92. — Frontal  section  through  the  meatus,  tympanic  membrane,  and 
cavity  ;  right  ear :  0,  Pneumatic  spaces  in  the  superior  wall  of  the  meatus  con- 
necting with  the  middle  ear ;  d,  roof  of  the  drum  cavity  ;  m,  inferior  wall ; 
t,  drum  cavity  ;  h,  head  of  malleus ;  g,  manubrium  ;  a,  anvil ;  s,  stapes  ;  c, 
cross-section  of  Fallopian  canal ;  f,  jugular  fossa  ;  k,  posterior  wall  of  bony 
meatus ;  /,  inferior  wall  of  meatus ;  dr,  glandular  openings  in  the  external 
meatus   (Politzer). 

plexus.     Besides  these  a  branch  from  the  pneumogastric 
nerve  supplies  the  meatus  as  far  as  the  drumhead. 

276.  The  tympanic  cavity  is  formed  by  a  niche  on  the 
external  surface  of  the  petrous  bone.  It  is  completed  as 
a  closed  chamber  by  the  articulation  with  the  squamous 
part  of  the  temporal  bone  at  the  upper  external  border, 
with  the  annulus  tympanicus  all  around,  and  with  the 
2.3 


354  ANATOMY   AND    PHYSIOLOGY    OF   THE    EAR 

mastoid  process  posteriorly.  It  is  an  irregular-shaped 
cavity,  flattened  in  the  transverse  direction  (Fig.  92). 
The  external  wall  is  formed  largely  by  the  membrana 
tympani  and  its  bony  frame.  This  thin  membrane  (o.  i 
mm.  thick)  is  stretched  across  the  annulus  tympanicus, 
being  fastened  in  the  groove  on  its  concavity.  About  one- 
seventh  part  of  this  bony  ring  is  absent  at  the  upper 
periphery,  and  here  the  drumhead  is  attached  to  the  mar- 
gin of  a  crescentic  gap  in  the  squamous  portion — Rivini's 
incisure.  This  extra-annular  area  of  the  drumhead  is 
called  the  flaccid  portion,  or  Shrapnell's  membrane.  The 
drumhead  consists  of  thin  true  skin  on  its  outer  side, 
delicate  mucous  membrane  on  the  tympanic  side,  with  a 
double  layer  of  connective-tissue  fibers  between.  The 
fibers  are  arranged  radially  in  the  external  layer  and  in 
concentric  circles  in  the  inner  layer.  This  fibrous  layer, 
to  which  the  membrane  owes  its  firmness,  is  wanting  in 
the  flaccid  portion.  At  its  insertion  in  the  groove  of  the 
bony  ring  the  fibrous  layer  is  thickened  in  the  form  of  a 
tendinous  ring  (Fig.  92).  The  membrane  is  grayish  and 
translucent. 

The  plane  of  the  drumhead  is  not  vertical,  but  slants 
downward  and  inward  and  forward  and  inward.  In  an 
imperfect  view  through  the  meatus  it  seems  to  be  nearly 
the  continuation  of  the  posterior  upper  wall  of  the  meatus. 
The  membrane,  however,  does  not  lie  in  a  single  plane, 
but  has  a  peculiar  curvature  which  can  be  artificially 
imitated  in  the  following  way  :  If  a  flexible  but  plastic 
membrane  (moist  bladder)  is  stretched  across  the  wide 
mouth  of  a  bottle  and  pressed  down  in  its  center  by  an  im- 
pinging rod,  the  membrane  becomes  conic,  with  its  apex 
toward  the  interior,  while  each  radius  from  periphery  to 
center  assumes  a  curve  with  convexity  outward.  This 
shape  has  been  proved,  both  by  trial  as  well  as  mathemat- 
ically, to  be  the  most  favorable  for  the  reception  of  sound- 
waves. The  shape  of  the  drumhead  is  even  more  com- 
plicated, because  the  traction  is  not  merely  exerted  at  its 
center,  but  from  the  center  to  nearly  the  upper  periphery 


TYMPANIC    CAVITY.  355 

by  the  linear  attachment  of  the  handle  of  the  hammer. 
The  handle  of  the  hammer  is  oblique  with  reference  to 
all  axes  of  the  head,  its  lower  end  pointing  inward  at  an 
angle  of  35  degrees,  and  also  slightly  backward  as  com- 


FlG.  93. — Normal  membrana  tympani  (left),  enlarged. 

pared  with  its  upper  end.  The  tympanic  cavity  is  nar- 
rowed to  about  2. 5  mm.  at  the  level  of  the  center  of  the 
drumhead,  by  reason  of  this  inward  depression. 

The  attachment  of  the  hammer  divides  the  drumhead 


hi-- 


Fig.  94. — Inner  surface  of  the  left  membrana  tympani  enlarged :  h.  Head 
of  malleus  ;  ha,  neck  of  malleus  ;  mt,  tendon  of  the  tensor  tympani  muscle 
and  anterior  fold  of  the  drumhead  ;  «,  inferior  end  of  the  manubrium  ;  v,  an- 
terior half  of  the  drumhead  ;  hd,  posterior  fold  of  the  drumhead  and  chorda 
tympani  nerve;  a,  anvil  ;  A', its  short  process  ;  /,  its  long  process  (Politzer). 

into  an  (smaller)  anterior  and  (larger)  posterior  half.  The 
prominence  of  the  upper  end  of  the  handle  (or  short 
process)  causes  the  appearance  of  an  anterior  and  a  poste- 
rior fold  radiating  peripherally  from  this  sharp  point. 


356       ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 

These  "creases"  are  exaggerated  when  the  membrane  is 
morbidly  retracted.  On  the  internal  surface  of  the  mem- 
brana  tympani  the  handle  of  the  hammer  is  seen  attached 
along  its  entire  length — from  its  projecting  neck  to  its 
flattened  lower  end  (Fig.  94).  At  the  lever  of  its  upper 
insertion  into  the  drumhead  the  mucous  membrane  is 
raised  in  the  form  of  two  folds  or  ridges — the  more  promi- 
nent posterior  and  the  lesser  developed  anterior  fold — ex- 
tending to  the  bony  margin.  They  correspond  nearly 
in  site  with  the  projecting  creases  marked  on  the  external 
surface.  These  duplicatures  of  mucous  membrane  form 
pockets  with  the  flaccid  portion  of  the  membrane.  The 
chorda  tympani  nerve,  which  leaves  the  facial  nerve  at 
the  upper  end  of  the  Fallopian  canal,  passes  across  the 
membrana  tympani  along  this  fold  or  ridge  to  the  Glase- 
rian  fissure  in  front  and  above,  where  it  emerges  from  the 
drum  cavity. 

The  area  of  the  membrana  tympani  is  an  ellipse,  with 
its  long  axis  tilted  slightly  forward,  the  long  diameter 
being  about  10  mm.,  the  short  diameter  about  9  mm. 
At  the  upper  margin  the  flaccid  portion  extends  slightly 
beyond  the  elliptic  outline. 

277.  The  floor  of  the  tympanic  cavity  is  2  to  3  mm. 
below  the  level  of  the  inferior  margin  of  the  membrane. 
Above  the  upper  margin  of  the  drumhead  the  cavity  ex- 
tends upward  5  to  6  mm.,  being  slightly  higher  behind 
than  in  front.  This  upper  space  is  known  as  the  attic  (Fig. 
95).  The  external  wall  of  the  attic  is  furnished  by  the 
up-turned  lower  plate  of  the  squamous  part  of  the  tem- 
poral bone.  The  upper  or  cerebral  plate  of  its  hori- 
zontal portion  projects  slightly  inward  and  helps  to  form 
the  roof  of  the  drum  cavity,  being  overlapped  by  a 
lamella  from  the  petrous  bone.  Through  the  suture 
between  the  squamous  and  petrous  parts  there  extends  a 
vascular  process  from  the  dura  mater  in  childhood,  which 
obliterates  later  on.  At  the  upper  front  corner  of  the 
suture  between  petrous  and  tympanic  portion  a  chink  is 
left  in  the  bone, — the  Glaserian  fissure, — through  which 


TYMPANIC    CAVITY. 


357 


the  chorda  tympani  nerve  leaves  the  drum  cavity.  The 
narrow  roof  of  the  drum  cavity  slants  downward  and 
forward.  It  consists  usually  of  cancellated  bone  2  to  3 
mm.  thick,  but  may  be  reduced  to  a  thin  plate,  which 
is  sometimes  defective,  permitting  contact  between  the 
dura  and  tympanic  mucous  membrane. 


Fig.  95. — Eustachian  tube  and  tympanic  cavity  in  connection :  t,  Mem- 
brana  tympani;  h,  head  of  malleus  ;  «,  lower  end  of  the  handle  of  the  ham- 
mer ;  a,  body  of  the  incus  ;  K,  short  process  of  the  incus  ;  m,  tensor  tympani 
muscle  ;  o,  pharyngeal  end  of  the  Eustachian  tube ;  i,  isthmus  of  the  Eusta- 
chian tube  ;  ot,  tympanic  opening  of  the  Eustachian  tube;  right  ear  (Politzer). 

The  posterior  wall  is  represented  below  by  a  narrow 
curved  gutter  formed  by  the  junction  of  external  and 
internal  walls.  It  widens  upward,  and,  at  the  level  of 
the  upper  margin  of  the  drumhead,  an  opening  leads  into 
the  mastoid  antrum.  This — the  aditus — is  of  triangular 
shape,  with  base  upward.     Underneath  it  is  a  conic  pro- 


358       ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 

jection,  the  eminentia  pyramidalis.  In  a  tunnel  in  its 
interior  the  short  pear-shaped  stapedius  muscle  is  attached 
and  hidden,  only  its  tendon  emerging  from  the  hole  at 
the  apex.  The  inferior  wall,  narrower  than  the  superior, 
presents  a  roughened  surface.  Underneath  it  is  the  bulb 
of  the  jugular  vein.  This  wall  is  of  variable  thickness, 
sometimes  partially  defective.  The  anterior  boundary 
of  the  tympanic  cavity  is  formed  by  the  forward  slant  of 
the  internal  wall.  Outside  of  it  (anteriorly)  is  the  canal 
of  the  carotid  artery.  Below  the  level  of  the  upper  part 
of  the  membrana  tympani  is  the  opening  into  the  Eusta- 
chian tube,  of  funnel  shape  and  without  sharp  boundary 
between  drum  cavity  and  tube.  It  is  about  3.5  mm. 
wide  and  4.5  mm.  high.  Above  the  Eustachian  tube 
and  parallel  with  it  is  a  narrow  bony  canal  for  the  tensor 
'tympani  muscle. 

The  internal  wall,  a  thin  but  firm  plate  of  bone,  sepa- 
rates the  drum  cavity  from  the  labyrinth.  Its  center  is 
marked  by  a  prominence — the  promontory  formed  by  the 
projection  of  the  first  turn  of  the  cochlea.  Above  and 
behind  the  promontory  is  the  oval  window^  4  mm.  in  its 
transverse,  1.5  mm.  in  its  vertical,  diameter.  It  is  the 
opening  into  the  vestibule  and  is  closed  by  the  foot-plate 
of  the  stapes.  The  plane  of  this  window  slants  downward 
and  inward.  It  is  set  deeply  in  a  niche  into  which  the 
foot-plate  of  the  stirrup  fits.  About  3  to  4  mm.  below 
the  oval  window,  and  hence  below  and  behind  the  prom- 
ontory, is  the  smaller  round  or  triangular  window 
which  leads  into  the  cochlea.  It  is  closed  by  a  mem- 
brane, the  membrana  secundaria.  The  facial  nerve 
coming  from  the  interior  passes  in  a  curve  over  the 
vestibule  and  thence  runs  in  the  slightly  projecting  Fal- 
lopian canal  (sometimes  a  mere  groove),  with  a  concave 
turn  above  and  behind  the  oval  window.  The  canal 
pursues  its  visible  course  downward  at  the  junction  of 
internal  and  posterior  wall,  and  through  it  the  facial 
nerve  reaches  its  exit  through  the  stylomastoid  foramen 
(Fig.  96). 


TYMPANIC    CAVITY. 


359 


278.  The  tympanic  cavity  is  lined  by  a  delicate 
mucons  membrane  containing  few  mucous  glands.  The 
epithelium  is  ciliated,  cylindric  in  the  lower,  but  flattened 
in  the  upper,  areas.  The  deeper  layer  of  mucous  mem- 
brane serves  as  periosteum.  The  membrane  follows  the 
surface  accurately,  but  is  raised  in  the  form  of  the  re-' 
duplications  or  folds  across  the  upper  part  of  the  drum- 
head, while  several  inconstant  folds  are  usually  found 
between  the  walls  and  the  upper  part  of  the  ossicles. 
The  mucous  membrane  lines  the  ossicles  as  well  as  their 


Fig.  96. — Sagittal  section  through  the  entire  middle  ear  of  the  adult,  inner 
half  of  left  ear :  op.  Pharyngeal  end  of  Eustachian  tube  ;  ot,  tympanic  opening 
of  Eustachian  tube ;  te.  Eustachian  tube  ;  //,  tensor  tympani  muscle  ;  p,  prom- 
ontory with  Jacobson's  nerve  across  it ;  u,  inferior  tympanic  wall  ;  st,  stapes ; 
sp,  stapedius  muscle ;  /,  facial  nerve ;  an,  mastoid  antrum ;  w,  w' ,  mastoid 
cells  (Politzer). 


various  ligaments.     It  is  continuous  with  the  lining  of 
the  mastoid  antrum  and  that  of  the  Eustachian  tube. 

The  ossicles,  three  in  number,  form  a  bony  chain  from 
drumhead  to  oval  window.  The  hammer  or  malleus  has 
a  club-shaped  head  with  an  articulating  surface  for  the 
anvil.  The  tapering  neck  has  a  projecting  knob,  the 
short  process,  inserted  at  the  upper  end  of  the  drumhead, 
from  which  the  handle  or  manubrium  descends  at  an 
obtuse  angle,  terminating  in  a  flattened  end.  The  point 
of  attachment  of  this  end  near  the  middle  of  the  drum- 


36o 


ANATOMY   AND    PHYSIOLOGY    OF    THE    EAR. 


head    is    termed   the   umbo.       From    the   neck   of    the 
hammer  a  slender  bony  process — the  long  process — ex- 

1  2  3 

Fig.  97. — The  ossicles  of  the  middle  ear:  I,  The  malleus:  k,  head;  h, 
neck  ;  gr,  manubrium  ;  /,  long  process  ;  g,  articular  surface.  2,  The  incus  : 
k,  body;  0,  short  process;  /,  long  process;  g,  articular  surface;  s,  cog  beneath 
the  articulation.  3,  The  stapes :  k,  articulating  head ;  S,  crus  stapedii ;  /, 
foot-plate  (Politzer). 

tends  forward  to  the  Glaserian  fissure   (Fig.   97).     The 
anvil  or  incus  resembles  in  shape  a  molar  tooth  with  two 

roots.  Its  articulating  sur- 
face, like  that  of  the  ham- 
mer, is  saddle-shaped.  The 
long  process  descends  slant- 
ingly in  ward  and  somewhat 
posteriorly,  and  is  attached 
to  the  stapes.  The  hori- 
zontal short  process  points 
into  the  mastoid  aditus. 
The  stirrup  or  stapes  has 
the  exact  shape  indicated 
by  its  name.  Its  head,  a 
detached  button  of  bone, 
articulates  with  the  long 
process  of  the  anvil,  while 
the  foot-plate  fits  into  the 
oval  window.  Between 
head  and  foot-plate  are  the 
two  crura.  The  articula- 
tions between  hammer  and 


Fig.  98. — Tympanic  cavity  exposed 
by  removal  of  the  roof,  showing  the  liga- 
ments of  the  ossicles :  h,h.  Head  of  the 
malleus ;  La,  ligament,  mallei  ant. ; 
Le,  ligament,  mallei  ext.;  K,  project- 
ing spina  tymp.  post. ;  a,  mastoid  antrum 
(Politzer). 


anvil  and  anvil  and  stirrup  are  true  joints  with  minute 
plates  of  cartilage  and  capsular  ligaments.  .  The  foot- 
plate of  the  stirrup  is  attached  to  the  margin  of  the  oval 
window  by  an  encompassing  annular  ligament.     While 


TYMPANIC    CAVITY. 


361 


the  chain  of  ossicles  is  held  in  place  by  the  attachment  to 
the  drumhead  and  oval  window,  the  ossicles  are  steadied 
besides  by  additional  ligaments. 
A  short  superior  ligament  sus- 
pends the  head  of  the  hammer 
from  the  roof.  A  fan-shaped 
band  springing  from  the  neck  of 
the  hammer  inserts  itself  into  the 
margin  of  the  incisure  of  Rivini 
(Fig.  98).  A  similar  narrow  one 
attaches  itself  forward  along  the 
upper  anterior  corner  of  the  drum 
cavity.  This  anterior  ligament, 
together  with  the  extreme  poste- 
rior portion  of  the  external  liga- 
ment, forms  the  axial  cord  around 
which  the  hammer  can  vibrate. 
The  short  process  of  the  anvil  is 
also  steadied  by  a  small  ligament 
coming  from  the  upper  posterior 
tympanic  wall.  The  tensor  tym- 
pani  muscle,  a  thin  slender  mus- 
cle, originates  from  the  walls  of 
the  narrow  canal  in  the  bone, 
above  and  parallel  to  the  Eusta- 
chian tube.  Its  tendon,  travers- 
ing the  upper  part  of  the  tympanic 
cavity  from  the  anterior  internal 
corner  to  the  hammer,  attaches 
itself  at  the  junction  of  neck  and 
handle.  It  pulls  the  handle  in- 
ward. The  stapedius  muscle 
originates  and  is  concealed  in  the 
tunnel  in  the  eminentia  pyrami- 
dalis  at  the  lower  internal  portion  of  the  posterior  wall. 
Its  tendon  issues  through  the  minute  hole  in  the  emi- 
nentia, and  reaches  the  head  of  the  stapes,  which  it  can 
deflect  slightly  backward  and  downward. 


Fig.  99.  —  Microscopic 
section  through  hammer, 
drumhead,  and  external  part 
of  the  attic :  h.  Head  of  the 
hammer;  te,  tendinous  inser- 
tion of  the  membrana  tym- 
pani ;  b,  short  process  of  the 
hammer ;  «,  umbo ;  /,  trans- 
verse section  of  chorda  tym- 
pani  nerve;  e,  external  liga- 
ment of  hammer;  /,  superior 
ligament ;  s,  Shrapnell's  mem- 
brane ;  ae,  external  attic  ;  /, 
Prussak's  space ;  c,  a  vascu- 
lar channel  between  attic  and 
bony  meatus  (Politzer). 


3^62  ANATOMY   AND    PHYSIOLOGY    OF    THE    EAR. 

279«  The  ligaments  of  the  ossicles,  together  with  some 
irregular  and  inconstant  bridges  of  mucous  membrane, 
subdivide  the  attic  into  a  series  of  minute  chambers  (Fig. 
99).  The  most  constant  of  these  are  Prussak's  space, 
between  Shrapnell's  membrane,  short  process  of  hammer 
and  external  ligament,  and  the  external  part  of  the  attic 
between  the  external  wall  above  the  drumhead  and  the 
head  of  the  hammer.  All  these  spaces  communicate  nor- 
mally with  the  tympanic  cavity  through  minute  orifices. 
It  is  easy  to  see  how  readily  inflammatory  action  may 
lead  to  occlusion  of  these  spaces  and  retention  of  secre- 
tion. The  irregular  and  inconstant  arrangement  of 
bridges  of  mucous  membrane  from  the  walls  of  the  attic 
to  the  heads  of  the  ossicles  has  an  embr^-ologic  reason. 
Until  shortly  before  birth  the  drum  cavity  is  filled  with 
embryonic  connective  tissue,  which  then  undergoes  ab- 
sorption and  transformation  into  thin  mucous  membrane 
lining  all  the  contents  of  the  cavity. 

280.  It  is  important  for  surgical  purposes  to  be  able  to 
locate  the  tympanic  contents  with  reference  to  the  mem- 
brana  tympani.  It  must  be  remembered  that  the  plane 
of  the  drumhead  slants  obliquely  forward  and  inward 
as  well  as  downward  and  inward.  On  account  of  the 
curvature  of  the  membrane  the  area  above  the  umbo  and 
the  handle  of  the  hammer  is  at  an  angle  of  about  35 
degrees  with  the  vertical,  while  the  inferior  part  of  the 
drumhead  is  more  nearly  vertical.  By  the  imaginary 
downward  prolongation  of  the  handle  of  the  malleus  and 
an  imaginary'  horizontal  line  through  the  umbo  the  mem- 
brane is  divided  into  four  quadrants.  In  the  case  of  large 
perforation  or  total  loss  of  the  membrane  various  parts  of 
the  tympanic  cavity  can  be  seen  during  life,  although  the 
visible  field  depends  considerably  on  the  varying  size  and 
curvature  of  the  meatus  (Fig.  100).  The  anterior  upper 
quadrant  does  not  quite  permit  a  view  of  the  Eustachian 
orifice.  The  tendon  of  the  tensor  tympani  muscle, 
barely  visible,  is,  however,  accessible  to  the  knife. 
Through  the  posterior  inferior  quadrant  the  promontory 


TYMPANIC    CAVITY.  363 

and  often  the  round  window  are  visible.  The  posterior 
upper  fourth  of  the  membrane,  if  absent,  permits  a  view 
of  the  long  process  of  the  anvil,  its  articulation  with  the 
head  of  the  stapes,  the  posterior  crus  of  the  stapes,  and 
the  tendon  of  the  stapedius  muscle.  The  chorda  tympani, 
sometimes  visible  at  the  upper  margin  of  the  membrane 
as  a  transverse  filament,  can  be  reached  and  injured  by- 
instruments.  The  facial  nerve  in  its  canal  is  not  en- 
dangered by  the  ordinary  intratympanic  manipulations, 
but  must  be  carefully  avoided  in  resection  of  the  poste- 
rior wall  of  the  meatus. 

«8i.  The  Eustachian  tube,  about  3. 5  cm.  long,  passes 


Fig.  100. — Topographic  relation  of  drumhead  to  the  internal  tympanic 
wall  (schematic):  vo.  Anterior  upper  quadrant;  vu,  anterior  lower  quadrant; 
ho,  posterior  upper  quadrant;  hu,  posterior  lower  quadrant;  as,  articulation  of 
anvil  and  stapes;  r,  round  window;  s,  Shrapnell's  membrane  (Politzer). 

obliquely  downward,  forward,  and  inward  from  the  upper 
part  of  the  anterior  wall  of  the  tympanic  cavity  to  the 
side  of  the  pharynx  (compare  Figs.  95  and  96).  Its  upper 
third  is  formed  by  the  incomplete  bony  canal  in  the 
petrous  bone,  completed  partly  by  the  tympanic  portion 
externally  and  the  sphenoid  wing  in  front  and  above. 
There  is  a  gradual  transition  from  tympanic  cavity  to  the 
Eustachian  canal.  Thence  on  the  bony  passage  narrows 
until  near  its  end — the  so-called  isthmus — it  is  but  2  mm, 
high  and  i  mm.  wide.  The  lower  two-thirds  of  the 
tube — the  cartilaginous  portion — expands  in  the  opposite 
direction  up  to  the  pharyngeal  orifice,  which  shows  a 
height  of  9  mm.  by  a  width  of  5  mm.     The  principal 


364 


ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 


structure  of  its  wall  is  the  triangular  plate  of  cartilage 
which  forms  the  median  wall.  By  curving  at  its  upper 
border  in  the  form  of  a  hook  it  forms  also  the  roof  of  the 
tube  (Fig.  loi).  The  external  wall  and  floor  of  the  tube 
are  membranous.  The  Eustachian  cartilage  is  about  12 
mm.  high  and  5  mm.  thick  at  its  pharyngeal  end.  In 
its  length  of  25  mm.  it  tapers  toward  the  rear  to  a  height 
of  7  mm.  and  a  thickness  of  about  2  mm.     The  bony 


^i-Carf,/a, 


MathmtnU'/j 


Oifip»fli 


&xndiit*ue 
efJjnUiall. 


Fig.  ioi. — Vertical  section  through  the  middle  third  of  the  Eustachian  tube, 
showing  the  tubopalatal  muscles  (Randall). 


canal  expands  again  beyond  the  isthmus  (inward)  and 
the  cartilaginous  plate  is  set  into  this  opening.  Its  upper 
border  is  fastened  in  a  groove  between  petrous  bone  and 
sphenoid  wing.  It  is,  furthermore,  strengthened  by  a 
lamella  from  the  basilar  fibrocartilage.  The  projection 
of  the  Eustachian  cartilage  into  the  pharjmx  forms  the 
prominent  posterior  lip  of  the  Eustachian  orifice — the 
Eustachian   tumefaction — the   mucous    membrane   over 


TYMPANIC    CAVITY.  365 

which  is  thickened  by  an  adenoid  cushion.  The  orifice 
itself  is  a  funnel-shaped  niche  surrounded  by  a  triangular 
or  oval  frame,  formed  by  folds  of  mucous  membrane  (Fig. 
102).  Posterior  to  it  and  above  it  is  the  fossa  of  Rosen- 
miiller.  The  pharyngeal  mucous  membrane  is  contin- 
uous with  that  of  the  tube,  in  which  channel,  however, 
it  is  puckered  in  the  form  of  longitudinal  folds.     The 


Fig.  102. — Sagittal  section  of  frozen  head ;  left  head  ;  exact  representation  of 
Eustachian  orifice  and  surroundings  (Zuckerkandl). 

outer  wall  of  the  tube  is  formed  only  by  mucous  mem- 
brane strengthened  by  fibrous  tissue  and  thickened 
toward  its  upper  end  by  a  cushion  of  fat.  The  mucous 
membrane  continues  throughout  the  bony  part  as  a  more 
delicate  lining,  and  is  continuous  with  that  of  the  drum 
cavity.  The  pharyngeal  orifice  in  the  adult  is  at  the 
level  of  the  posterior  end  of  the  inferior  turbinal.  At 
birth  its  level  is  scarcely  above  that  of  the  palate,  while 


366  ANATOMY    AND    PHYSIOLOGY    OF    THE    EAR. 

the  entire  tube  at  that  time  is  relatively  much  shorter 
than  later  in  life. 

The  caliber  of  the  Eustachian  tube  forms  a  somewhat 
S-shaped  slit  throughout  the  cartilaginous  portion,  the 
walls  of  which  are  in  actual  contact.  In  the  bony  por- 
tion the  caliber,  though  much  smaller,  is  patent.  Gaping 
of  the  passage  occurs  only  during  the  act  of  swallowing, 
and  in  some  persons  while  yawning.  The  dilatation  of 
the  tube  is  due  to  the  action  of  two  muscles,  the  levator 
palati  and  the  tensor  palati.  The  former  arises  from  the 
petrous  bone  and  runs  parallel  to  and  underneath  the 
floor  of  the  Eustachian  tube  to  the  soft  palate.  During 
its  contraction  its  thickening  raises  the  floor  of  the  tube. 
The  tensor  palati  muscle  is  attached  to  the  inferior  sur- 
face of  the  sphenoid  wing — to  the  lower  lateral  end  of  the 
hook-shaped  cartilaginous  roof  of  the  tube,  as  well  as  to 
its  external  membranous  wall.  Descending  obliquely  it 
winds  itself  around  the  pterygoid  hamulus  and  inserts 
itself  into  the  fibrous  expansion  of  the  hard  palate.  By 
its  action  it  unrolls  the  curved  roof  and  pulls  outward 
the  external  wall  of  the  Eustachian  tube,  thereby  per- 
mitting its  gaping.  It  has  hence  been  termed  the  abduc- 
tor or  dilator  tubcB. 

282.  The  tympanic  cavity  communicates  toward  the 
rear  with  the  cavity  in  the  mastoid  process — the  mastoid 
antrum — and  the  adjoining  cells.  In  the  upper  part  of 
the  posterior  wall  there  is  a  triangular  opening,  with  base 
up, — the  aditus, — through  which  the  tympanic  attic  is 
continuous  with  the  mastoid  antrum.  The  latter,  an 
irregular  shaped  cavity  of  variable  size,  at  the  level  of 
the  attic  and  behind  the  tympanic  cavity,  is  surrounded 
by  smaller  air-cells  in  the  mastoid  process  and  often  com- 
municates with  air-spaces  in  the  petrous  bone  ;  some- 
times even  with  recesses  in  the  occipital  bone.  The  ex- 
tent of  these  pneumatic  spaces  is  especially  well  seen  in 
casts  made  by  corrosion  (Fig.  103). 

The  mastoid  process,  essentially  a  part  of  the  petrous 
portion,  is  covered  in  front  and  to  some  extent  externally 


MASTOID    PROCESS. 


367 


by  the  squamous  part  of  the  temporal  bone,  which  also 
forms  in  part  the  roof  of  the  antrum.  Between  squamous 
and  petrous  portions  is  the  mastoid  fissure,  which  oblit- 
erates gradually  during  childhood.  The  anterior  bound- 
ary is  the  posterior  wall  of  the  meatus.  Externally  it  is 
covered  by  thick,  tough  skin  firmly  united  with  the 
aponeurosis  and  the  periosteum.  At  its  lower  tip  the 
surface  is  roughened  for  the  attachment  of  the  sterno- 


FlG.  103. — Cast  of  the  Eustachian  tube,  tympanic  cavity,  mastoid  antrum, 
and  some  mastoid  cells  posterior  to  the  antrum,  viewed  from  the  external  side : 
I,  Incomplete  cast  of  a  cell  between  tube  and  anterior  tympanic  cavity;  2,  cel- 
lular dilatation  in  the  tympanic  roof;  3,  transverse  incisure  anterior  to  the 
aditus;  4,  cavity  in  which  the  heads  of  hammer  and  anvil  were  lodged;  5> 
site  of  short  process  of  anvil ;  6,  rear  end  of  antrum ;  7,  transitional  cell ;  8, 
terminal  cell   (Bezold). 

cleidomastoid  muscle.  In  its  interior  the  mastoid  pro- 
cess is  made  up  either  of  large  pneumatic  cells  (about 
one-third  of  all  instances)  or  of  firm  cancellated  bone 
(about  one-fifth  of  all  subjects),  or  both  types  of  bony 
structure  are  represented  to  a  variable  extent.  The 
larger  cells  are  continuous  with  the  antrum  through 
narrow  orifices  and  are  lined  by  thin  mucous  membrane. 
Smaller  cells  are  not  pneumatic,  but  contain  medullary 


368 


ANATOMY   AND    PHYSIOLOGY    OF   THE   EAR. 


Fig.  104. — Mastoid  process 
opened,  with  large  pneumatic 
spaces  (Politzer). 


Fig.  105. — Mastoid  process 
consisting  of  dense  bone  (Polit- 
zer). 


contents.     In  less  common  instances,    but  especially  in 
pathologic  cases,  the  bony  shell  may  be  quite  hard,  even 


Fig.  106. — Horizontal  section  through  mastoid  process  with  large  pneu- 
matic cells  (seen  from  above) :  t.  Tympanic  cavity ;  g,  posterior  wall  of  mea- 
tus; a,  mastoid  antrum;  S,  lateral  sinus;  w,7x/,  external  field  of  operation  in 
opening  into  the  mastoid  antrum  (Politzer). 

sclerotic  (Figs.  104  and  105).     The  roof  of  the  antrum  is 
usually  but  a  thin  plate  of  bone,  sometimes  partially  de- 


MASTOID    PROCESS.  369 

ficient.  Of  great  surgical  importance  is  the  relation  of 
the  antrum  to  the  lateral  venous  (or  transverse)  sinus. 
This  venous  channel  runs  in  a  groove  (sigmoid  fossa)  in 
the  bone,  passing  downward  and  forward  along  the  in- 
ternal surface  of  the  squamous  portion,  and  then,  with  a 
sharp  bend  behind  and  partly  above  the  antrum,  it  turns 
forward  and  inward  along  the  posterior  surface  of  the 
petrous  pyramid  to  reach  the  jugular  foramen.  The 
bony  groove  in  the  cerebral  plate  projects  into  the  antrum 
at  its  upper  posterior  corner — the  variable  extent  of 
which   cannot    be   predicted   from    external    inspection 


Fig.  107. — Horizontal  section  (seen  from  above)  through  the  temporal 
bone;  mastoid  process  of  relatively  dense  bone:  t.  Tympanic  cavity;  u,  in- 
ferior wall  of  external  meatus;  s,  groove  for  lateral  sinus;  w,  external  surface 
of  the  mastoid  process  (Politzer). 

(Figs.  106  and  107).  It  is  generally  a  little  lower  on  the 
right  side  than  on  the  left.  It  is  more  apt  to  encroach 
upon  the  antrum  when  the  bone  is  diploetic  than  when 
it  is  pneumatic.  In  operating  upon  the  mastoid  the  sur- 
geon must,  hence,  be  prepared  to  encounter  and  to  avoid 
the  lateral  sinus.  Suppurative  inflammation  of  the  mas- 
toid antrum  can  readily  involve  the  lateral  sinus  or 
extend  through  the  thin  roof  into  the  cranial  cavity. 
The  distance  of  the  antrum  from  the  external  surface  of 
the  bone  is  about  12  to  14  mm.  A  direct  route  to  it  is 
obtained  by  drilling  immediately  behind  the  auditory 
meatus  parallel  with  its  posterior  upper  wall. 

24 


370  ANATOMY   AND    PHYSIOLOGY    OF   THE    EAR. 

283.  The  mastoid  process  is  but  a  flat,  undeveloped, 
and  hence  scarcely  prominent  plate  at  birth.  The  cavity 
of  the  antrum  is  present,  but  is  covered  merely  by  a  thin 
shell  of  bone  without  pneumatic  spaces.  It  is  hence 
easily  reached  by  operation.  The  roof,  on  the  other 
hand,  is  relatively  thick,  so  that  during  early  infancy 
there  is  less  liability  to  cerebral  extension  of  mastoid 
disease. 

284.  The  middle  ear  is  well  supplied  with  numerous 
small  arteries  and  veins  entering  from  various  directions. 
None  of  them  are  of  sufficient  size  to  require  detailed 
description  for  surgical  purposes.  Through  Shrapnell's 
membrane  the  tympanic  vessels  anastomose  with  those 
of  the  meatus,  while  connecting  branches  between  drum 
cavity  and  the  internal  ear  penetrate  through  the  laby- 
rinthine wall.  The  membrana  tympani  has  a  small 
artery  with  a  vein  descending  along  the  handle  of  the 
hammer.  Between  these  vessels  and  the  periphery  there 
exist  branches  running  radially.  The  cutaneous  and 
the  mucous  layers  of  the  drumhead  have  each  a  separate 
set  of  vessels,  which,  however,  anastomose.  The  sensory 
nerves  of  the  drum  cavity  are  derived  partly  from  the 
trigeminus,  mainly  from  the  glossopharyngeus.  There 
are  also  fibers  from  the  sympathetic  nerves.  The  largest 
nerve-branches  are  found  on  the  internal  wall  of  the 
cavity.  The  facial  nerve  gives  off  two  branches  in  the 
Fallopian  canal — viz.,  one  for  the  stapedius  muscle  and 
the  chorda  tympani,  which  ascends  along  the  posterior 
wall  and  then  traverses  the  drum  between  the  neck  of 
the  hammer  and  the  anvil  along  the  folds  on  the  inner 
surface  of  the  drumhead. 

285.  The  internal  ear  or  labyrinth  is  situated  in  passages 
tunneled  out  in  the  interior  of  the  petrous  bone.  In  the 
adult  the  surrounding  bony  substance  differs  so  little  in 
consistency  from  the  capsule  of  the  labyrinth  that  its 
demonstration  by  dissection  is  very  difficult.  But  in  the 
new-born  the  spong}'  bone  substance  can  be  removed 
more  easily,  leaving  the  bony  labyrinth.     This  consists 


INTERNAL   EAR    OR    LABYRINTH. 


371 


of  vestibule,  cochlea,  and  semicircular  canals.  The 
vestibule  is  an  irregular  elliptic  cavity,  inward  from  the 
tympanum,  with  which  it  connects  through  the  oval 
window  (closed  by  the  stapes).     A  vertical  crest  on  its 


Catt.cxt. 


Co-rLp- 

^  ^  Fen.r.    Fen..o 

Fig.  108. — Left  bony  labyrinth  seen  from  the  external  side  and  somewhat 
from  below  (enlarged):  Can.  F,  Fallopian  canal ;  C,  cochlea;  Cu,  cupola;  Pi-, 
promontory;  Fen.  r,  round  window;  Fen.o,  oval  window   (Gegenbaur). 

internal  wall  divides  the  vestibule  into  an  anterior  spheric 
and  the  posterior  elliptic  recess  (Fig.  108).  Downward 
and  forward  it  is  prolonged  into  the  cochlea,  a  slightly 
tapering    tube   coiled   upon  itself  like  a  snail,  with  2| 


Fig.  109. — Section  through  the  cochlea  (enlarged) :  H,  Hamulus ;  Sc.v, 
scala  vestibuli ;  5^.^,  scala  tympani ;  Z.<?,  lamina  spiralis  ossea;  ^.?,  internal 
auditory  meatus   (Gegenbaur). 

turns,  the  terminal  coil  or  cupola  being  in  front.  The 
beginning  of  the  cochlea  causes  the  bulging  of  the 
internal  tympanic  wall,  known  as  the  promontory.  In 
the  axis  of  the  cochlea  bony  trabeculse  form  the  spindle 


372       ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 

or  modiolus,  a  conic  axis  with  a  screw-shaped  lamina 
projecting  into  the  coils  and  reaching  half-way  across 
them.  This  osseous  lamina  spiralis  is  completed  by  a 
membranous  extension  across  the  cochlear  passage  which 
divides  the  channel  into  an  upper  half,  the  scala  vestibuli, 
and  the  inferior  half,  the  scala  tympani  (Fig,  109).  This 
partition  does  not  quite  reach  to  the  end  of  the  cupola, 
where  the  two  scalae  communicate.  The  scala  vestibuli 
is  continuous  with  the  interior  of  the  vestibule.  The 
scala  tympani,  however,  is  closed  at  its  vestibular  end  by 
the  spiral  partition  wall.  Through  the  round  or  triangu- 
lar window  it  is  in  communication  with  the  drum  cavity. 
The  membranous  partition  in  the  cochlear  passage  con- 
sists, however,  of  two  layers,  between  which  a  third 
channel,  the  cochlear  duct,  is  left,  which  follows  the 
convolution  of  the  bony  tube  from  vestibule  to  cupola. 

On  the  posterior  side  of  the  vestibule  the  three  semi- 
circular canals  constitute  three  tunnels  in  the  bone, 
lying  in  three  planes  all  vertical  to  each  other.  Their 
planes  do  not  strictly  coincide  with  any  normal  plane  of 
the  head.  The  anterior  or  superior  semicircular  canal  lies 
nearly  in  the  frontal  plane.  The  internal  or  posterior  or 
inferior  vertical  semicircular,  the  longest  and  narrowest 
of  the  three,  lies  approximately  in  the  sagittal  plane, 
while  the  external  semicircular  canal,  the  shortest  and 
thickest,  is  about  horizontal,  with  its  vertex  toward  the 
rear.  It  projects  slightly  into  the  drum  cavity  behind 
the  Fallopian  canal.  The  external  ends  of  the  semi- 
circular canals  expand  in  the  form  of  the  ampullae,  while 
the  insertion  of  their  other  end  into  the  vestibule  has 
the  same  caliber  as  the  canal  itself.  The  superior  and 
the  posterior  semicircular  canal  unite  with  each  other  at 
their  junction  with  the  vestibule. 

386.  The  auditory  and  facial  nerves  enter  the  petrous 
pyramid  near  the  middle  of  its  posterior  surface,  through 
the  internal  auditory  meatus.  This  short  canal,  passing 
outward  and  somewhat  backward,  enlarges  into  a  pouch 
inward  from  the  vestibule.     Here  the  facial  nei^ve  sepa- 


INTERNAL  AUDITORY   MEATUS.  373 

rates  and  enters  the  Fallopian  canal,  passing  over  the 
vestibule  in  the  form  of  a  sharp  bend,  whence  it  pursues 
its  curved  course  toward  the  rear  and  downward.  The 
auditory  nerve,  however,  divides  into  its  branches,  two 
to  the  vestibule  and  one  to  the  cochlea,  which  latter 
enters  partly  direct  at  the  vestibular  end,  partly  gradually 
through  the  spindle,  in  which  it  pursues  a  spiral  course. 
In  this  spiral  passage  the  nerve  becomes  gangliform  by 
the  addition  of  nerve-cells.  Its  fibers  pass  in  a  comb- 
shaped  fashion  through  fine  perforations  in  the  lamina 
spiralis  into  the  cochlear  duct. 

287.  The  membranous  labyrinth  is  in  the  interior  of  the 
bony  chambers.  While  its  shape  resembles  that  of  the  bony 
labyrinth,  it  does  not  form  an  accurate  lining  for  the  lat- 
ter. Between  the  bony  walls  and  the  membranous  laby- 
rinth there  is  a  lymph-space  filled  with  a  fluid,  known  as 
the  perilymph.  The  bony  labyrinth  is  lined  by  a  delicate 
periosteum  with  endothelial  cells.  The  interior  of  the 
membranous  labyrinth  is  also  filled  with  a  fluid — the 
endolymph.  The  perilymphatic  space  communicates 
with  the  subarachnoid  space  of  the  brain  through  the 
cochlear  aqueduct.  The  latter,  a  fine  membranous  tube, 
passes  from  the  closed  end  of  the  scala  tympani  through 
the  petrous  pyramid  to  its  lower  posterior  margin,  where 
it  becomes  continuous  with  the  meninges.  A  similar 
passage,  the  vestibular  aqueduct,  puts  the  endolymph 
into  communication  with  the  cerebral  lymph-spaces.  It 
begins  in  the  form  of  two  minute  passages  from  the 
membranous  sacs  in  the  vestibule, — one  from  the  utricu- 
lus,  the  other  from  the  sacculus, — which  unite,  pass 
through  the  pyramid,  and  empty  into  the  cistern  on  the 
middle  of  its  posterior  surface.  This  latter  small  closed 
bag  communicates  probably  through  microscopic  chan- 
nels with  the  subdural  space  (Fig.   no). 

«88.  The  interior  of  the  vestibule  contains  two  mem- 
branous pouches,  the  utriculus  and  the  sacculus,  which 
communicate  with  each  other  only  through  the  branches 
of  the  forked  vestibular  aqueduct.      The   posterior  of 


374       ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 

these  bags,  the  utricle,  much  smaller  than  the  vestibule, 
is  attached  to  its  internal  surface.  It  is  continuous  with 
the  membranous  semicircular  canals.  These  tubes  line 
the  bony  ampullae,  but  contract  in  the  bony  semicircular 
canals  to  the  tubules  much  smaller  than  the  bony  tunnels. 
They  are  fastened  along  the  convex  wall  and  steadied  by 
transverse  bands.  All  these  membranous  passages  are 
lined  by  flat  epithelium.  In  the  utricles  and  in  the 
ampullae  the  wall  is  thickened  in  spots,  termed  maculae, 
where  the  epithelium  changes  into  cylindric  cells  with 
long  cilia.  These  hair-like  processes  are  covered  with  a 
sticky,  jelly-like  substance,  in  which  crystals  or  carbonate 


Fig.  iio. — Rear  view  of  the  bony  labyrinth  at  birth  (enlarged):  co. 
Cochlea ;  mi,  internal  meatus  auditorius ;  ac,  aquaeductus  cochleae ;  av,  aquae- 
ductus  vestibuli  (Politzer). 

of  lime — the  otoliths — are  suspended.  As  these  ciliated 
cells  are  supplied  by  nerve-fibers  they  are  considered  the 
sensory  terminations  of  the  nerve. 

The  sacculus,  the  smaller  and  anterior  of  the  vestibular 
pouchjes,  is  fastened  likewise  to  the  internal  wall  of  the 
vestibule.  Its  structure  and  interior  are  similar  to  those 
of  the  utricle.  Through  a  very  fine  tubule  it  com- 
municates with  the  cochlear  duct,  which  latter  apparently 
terminates  at  the  cochlear  end  of  the  vestibule  in  a  blind 
cul-de-sac. 

289.  The  cochlear  duct  is  the  most  complicated  of  all 
labyrinthine  structures  (Figs.  11 1  and  112).  This  spirally 


INTERNAL   AUDITORY   MEATUS. 


375 


wound  passage   is  triangular   in  cross-section.     Its  wall 
next  to  the  scala  tympani — the  inferior   lamella  of  the 


Fig.  III. — Enlarged  section  of  the  cochlea  of  the  new-born:  Sc.v,  Scala 
vestibuli ;  .S*^.  /,  scala  tympani ;  K,  lamina  spiralis  ossea ;  b,  lamina  basilaris ; 
/,  triangular  ligament;  R,  Reissner's  membrane;  Cc,  cochlear  canal;  o,  organ 
of  Corti ;  ni,  Corti's  membrane;  n,  fasciculus  of  cochlear  nerve-fibers;  g,  spiral 
ganglion  (Politzer). 

lamina  spiralis — is  known  as  the  basilar  membrane.  This 
increases  in  width  from  the  cochlear  end  to  the  cupola. 


Fig.  112. — Terminal  apparatus  of  the  cochlear  nerves  in  the  organ  of  Corti 
of  man  (enlarged)  :  o.  Lamina  spiralis  ossea  with  cochlear  nerve-fibers;  p—l, 
lamina  spiralis  membranacea ;  H,  Huschke's  cog,  or  crista  spiralis ;  c,  inner 
column  of  Corti ;  d ,  outer  column  of  Corti  ;  r,  lamina  reticularis  ;  Z,  cells  of 
Corti ;  D,  Deiters'  cells ;  ih,  inner  ciliated  cell  ;  ah,  four  outer  ciliated  cells ; 
e,  radiating  cochlear  nerve-fibers  passing  to  Corti's  cells  ;  K,  cells  of  the  sulcus 
spiralis  internus ;  CI,  Hensen's  supporting  cells ;  Cm,  Corti's  membrane ;  Vs, 
vas  spirale  (Retzius). 

It  is  made  up  of  transverse  fibers  capable  of  vibrating 
individually.     The  superior  plate  of  the  lamina  spiralis 


376  PHYSIOLOGY    OF   THE    EAR. 

separating  the  cochlear  duct  from  the  vestibular  scala  is 
known  as  Reissner's  membrane.  The  external  wall  next 
to  the  bony  capsule  is  highly  vascular  and  is  termed  the 
stria  vascularis.  The  flat  epithelium  which  lines  the 
cochlear  duct  changes  into  cylindric  cells  with  long 
cilia  on  the  surface  of  the  basilar  membrane  next  to  the 
osseous  lamina.  These  constitute  the  organ  of  Corti,  the 
presumptive  sensory  termination  of  the  auditory  nerve 
(compare  Fig.  112).  Near  the  center  of  this  epithelial 
prominence  is  a  longitudinal  tunnel  lined  on  both  sides 
by  a  row  of  lengthened  (non-ciliated)  epithelial  cells,  the 
columns  of  Corti,  which,  by  inclining,  meet  at  the  top 
and  inclose  this  tunnel.  The  nerve  fibrils  coming  through 
the  osseous  lamina  spiralis  terminate  in  the  ciliated  cells. 
The  cilia  are  covered  by  a  cuticular  plate,  the  membrana 
tectoria,  which  arises  from  the  apex  of  the  triangular 
cochlear  duct. 

PHYSIOLOGY  OF  THE  EAR. 

390.  Sound  is  perceived  when  the  ear  is  reached  by 
aerial  vibrations  ranging  in  frequency  from  about  16  to 
50,000  a  second.  But  it  is  only  between  the  range  of  40 
and  4000  vibrations  a  second  that  sounds  can  be  employed 
for  pleasurable  musical  purposes.  The  theoretically  sim- 
plest form  of  vibration  is  that  described  by  a  swinging 
pendulum,  and  is  termed  mathematically  a  sinus  wave. 
Such  sinus  waves  produce  simple  tones.  They  can  be 
obtained  by  means  of  some  forms  of  open  organ-pipes  or 
from  tuning-forks  mounted  on  resounding  boxes.  Almost 
all  tones  produced  by  other  means  are  complicated,  con- 
sisting of  a  fundamental  note  with  a  variable  number  of 
overtones.  Their  graphic  representation  is  hence  entirely 
different  from  that  of  a  sinus  wave.  The  number  and 
height  of  overtones,  combined  with  the  fundamental  note, 
give  each  sound  the  characteristic  termed  musically  the 
timber,  or  quality.  The  trained  ear  can  detect  these 
overtones  within  certain  limits.  By  means  of  so-called 
resonators  their  existence  can  be  demonstrated  physically 


SOUND.  377 

(Fig.  113).  Noises  differ  from  tones,  first,  by  having  a 
large  number  of  discordant  overtones,  and,  secondly,  by 
the  irregularity  of  their  duration. 

The  funnel-shaped  and  movable  auricle  of  animals  aids 
in  locating  sounds,  as  the  sound  is  loudest  when  the 
auricle  points  in  its  direction.  In  man  this  function  is 
lost,  and  the  auricle  is  of  but  little  use  in  intensifying 
sound-waves  by  reflection. 

The  membrane  of  the  drum  is  remarkably  sensitive  to 
sound-waves,  both  on  account  of  its  thinness  and  espe- 
cially by  reason  of  its  curvature.  It  is  set  into  vibration 
by  any  sound-waves  entering  the  meatus.  By  reason  of 
the  curvature  of  its  radial  fibers  the  low  energy  of  sound- 


FlG.  113. — Helmholtz's  resonator. 

waves  suffices  to  produce  a  sufficient  mechanical  effect 
upon  the  handle  of  the  hammer  to  cause  it  to  vibrate. 
The  hammer  is  thus  made  to  swing  around  an  axis  formed 
by  the  ligaments  attached  to  its  neck.  This  vibration  is 
transmitted  through  the  articulation  to  the  head  of  the 
anvil,  and  through  tlie  long  process  of  the  latter  to  the 
stapes.  With  sufficiently  intense  tones  visible  vibrations  of 
the  drum  membrane  and  ossicles  may  be  obtained.  Under 
ordinary  circumstances,  however,  their  extent  of  move- 
ment is  of  microscopic  dimension.  When  the  membrana 
tympani  is  pressed  inward,  the  pressure  is  transmitted 
through  the  stapes  to  the  perilymph  of  the  labyrinth, 
and  the  membrane  of  the  round  window  can  be  made  to 
bulge  visibly.  Sound-waves  thus  travel  through  the 
perilymphatic  space  of  the  vestibule  and  the  vestibular 
scala  of  the  cochlea,  returning  from  the  end  of  the  latter 


3/8  PHYSIOLOGY    OF    THE    EAR. 

by  way  of  the  scala  tyrapani'  to  the  round  window. 
Through  the  thin  membranous  walls  of  the  cochlear 
duct  the  vibrations  are  communicated  to  the  endolymph. 
According  to  the  theory  of  Helmholtz,  there  are  in  the 
cochlear  duct  structures  tuned  to  resound  with  all  notes, 
and  these  are  presumably  the  fibers  of  the  basilar  mem- 
brane. How  these  sympathetic  vibrations  are  trans- 
formed into  activity  of  the  individual  nerve-fibers  is  as 
yet  beyond  our  comprehension. 

The  inward  movement  of  the  hammer  is  accurately 
followed  by  the  corresponding  motion  of  the  anvil  by 
reason  of  minute  cogs  on  both  ossicles  underneath  the 
articulation,  which  interlock  during  inward  movement. 
But  when  any  traction  pulls  the  manubrium  outward, 
the  anvil  does  not  follow  beyond  the  slight  limit  set  by 
the  elasticity  of  its  ligaments. 

There  is  not  much  known  about  the  functions  of  the 
muscles  of  the  ossicles.  It  has  been  shown  in  animals 
that  the  tensor  tympani  pulls  the  hammer  inward  at  the 
beginning  of  every  loud  sound.  This  is  a  momentary', 
not  a  continuous,  muscle-jerk  of  reflex  nature.  Some 
persons  can  contract  the  tensor  tympani  voluntarily  in 
connection  with  yawning  movements,  and  during  this 
period  they  hear  a  low  humming  sound  and  are  less 
sensitive  to  external  sounds.  The  tensor  tympani  muscle 
is  under  the  control  of  motor  fibers  of  the  fifth  nerve,  while 
the  stapedius  muscle  is  innervated  by  the  facial  nerve. 

291.  The  sensitiveness  of  the  membrana  tympani  to 
sound-waves  is  greatest  when  the  air-pressure  is  equal  on 
its  two  sides.  This  equilibrium  is  maintained  by  periodic 
ventilation  of  the  drum  cavity  through  the  Eustachian 
tube.  The  walls  of  the  cartilaginous  part  of  the  tube 
are  in  actual  contact,  but  this  contact  is  overcome  easily 
by  any  increased  air-pressure  in  the  pharynx.  Hence  on 
closing  the  nostrils  and  mouth  and  raising  the  pharyn- 
geal air-pressure  by  an  expiratory  effort  air  can  be  forced 
through  the  tube  into  the  middle  ear  (Valsalva's  experi- 
ment).    The  diminution  of  the  pharyngeal  air-pressure 


SOUND-WAVES.  379 

during  an  inspiration  with  closed  nostrils  and  mouth  is 
not  sufficient  to  open  the  tubal  walls.  But  if  a  swallow- 
ing movement  be  performed  while  the  nostrils  are  held 
closed,  the  air  is  sucked  out  of  the  tube  and  middle  ear 
(Valsalva's  negative  experiment).  The  Eustachian  tube 
gapes  normally  during  the  act  of  swallowing,  by  reason 
of  the  combined  action  of  the  tensor  and  levator  palati 
muscles.  During  this  momentary  dilatation  of  the  tubal 
caliber  the  normal  ventilation  of  the  middle  ear  takes 
place.  In  some  persons  the  tube  also  opens  during 
yawning.  The  gaping  of  the  Eustachian  tube  during 
swallowing  can  be  shown  by  holding  a  sounding  tuning- 
fork  in  front  of  the  nostrils.  The  sound,  ordinarily  in- 
audible, is  heard  during  the  act  of  swallowing.  When 
the  tube  is  obstructed  morbidly,  the  air  in  the  middle  ear 
is  gradually  absorbed  by  the  blood  in  the  capillaries,  and 
its  tension  is  lowered  below  that  of  the  external  atmos- 
phere. The  external  air  then  presses  the  membrana 
tympani  inward,  thereby  producing  a  feeling  of  fulness 
and  a  diminished  sensitiveness  to  sounds. 

292.  The  admission  of  sound-waves  to  the  drumhead 
is  interfered  with  by  any  occlusion  of  the  meatus.  But 
when  there  is  still  a  narrow  path  left,  sounds  are  only 
moderately  enfeebled.  Small  holes  in  the  membrana 
tympani  do  not  interfere  much  with  its  normal  function. 
Larger  defects  reduce  its  action  upon  the  hammer  in 
proportion  to  their  extent.  Even  in  total  absence  of  the 
membrana  tympani  and  ossicles  the  hearing  power  may 
be  still  practically  useful,  though  much  enfeebled.  Any 
morbid  process,  however,  which  interferes  with  the 
mobility  of  the  ossicles,  such  as  contact  with  the  swollen 
mucous  membrane  or  rigidity  of  the  articulations,  re- 
duces the  transmission  of  sound  to  the  oval  window  to  a 
large  extent.  Of  all  obstacles  to  soimd-conduction  none 
are  more  damaging  than  ankylosis  of  the  foot-plate  of 
the  stirrup  in  the  oval  window.  But  even  in  this  condi- 
tion sound-waves  reaching  the  drumhead  are  still  faintly 
perceived. 


380  PHYSIOLOGY    OF    THE    EAR, 

293.  Sound-waves  can  reach  the  labyrinth  through 
another  route  besides  the  conduction  from  the  drumhead 
through  the  ossicles  to  the  oval  window.  When  waves 
are  made  to  pass  through  the  bones  of  the  skull,  they 
reach  the  labyrinth  and  cause  the  sensation  of  sound. 
This  is  termed  bone-conduction.  Sound-waves  in  the 
air,  however,  do  not  cause  perceptible  vibration  of  the 
skull  bones,  except  in  the  case  of  very  high  notes.  Such 
high  tones,  produced,  for  instance,  by  the  Galton  whistle 
or  by  the  chirping  of  insects,  are  perceived  nearly  as 
well  when  the  meatus  is  occluded.  All  sound-waves, 
however,  can  be  passed  through  the  cranial  bones  by 
placing  the  latter  in  contact  with  the  vibrating  solid — 
for  instance,  the  stem  of  a  tuning-fork.  Aerial  waves  can 
be  conducted  into  the  skull  by  a  thin  elastic  plate  of 
rubber  (the  audiphone)  held  between  the  teeth.  But 
their  intensity  is  far  below  that  obtained  by  conduction 
through  the  normal  drumhead  and  ossicles. 

When  sound-waves  reach  the  two  healthy  labyrinths 
by  bone-conduction,  the  sensation  is  not  referred  to 
either  ear,  but  simply  to  the  head.  But  if  an  obstacle 
exists  to  sound-conduction  either  in  the  meatus  or  in  the 
chain  of  ossicles,  the  sound  perceived  through  bone-con- 
duction is  heard  loudest  in  the  ear  thus  impaired.  If, 
for  instance,  a  tuning-fork  be  placed  against  the  teeth  or 
the  forehead,  it  is  heard  loudest  in  the  ear  the  meatus  of 
which  is  occluded.     This  is  known  as  Weber's  test. 

The  binaural  perception  of  aerial  sound-waves  enables 
us  to  detect  the  direction  from  which  the  sound  comes. 
When  both  ears  are  normal  and  alike,  the  observer  re- 
cognizes the  greater  loudness  in  the  ear  turned  toward 
the  source  of  sound,  and  by  gradual  movements  of  the 
head  is  able  to  locate  it. 

294.  The  internal  ear  serves  as  the  organ  of  another 
sense  besides  that  of  hearing.  For  want  of  a  better  term 
this  has  been  called  the  static  sense,  or,  less  appropriately, 
the  sense  of  equilibrium.  The  semicircular  canals  en- 
able vertebrate  animals  to  estimate  the  motion  of  their 


THE   STATIC    SENSE.  38 1 

bodies  relative  to  the  surrounding  space  as  well  as  their 
position  with  reference  to  the  action  of  gravity.  As  these 
sensations  do  not  ordinarily  enter  the  domain  of  conscious- 
ness with  the  vividness  characteristic  of  the  activity 
of  the  other  senses,  the  static  sense  is  not  recognizable 
by  self-observation,  except  under  selected  experimental 
conditions.  The  static  sense  can  be  demonstrated  sub- 
jectively by  rotating  the  observer  while  seated  on  a 
whirling  platform.  With  closed  eyes  one  perceives  un- 
mistakably the  direction  and  the  rapidity  of  the  rotation, 
until  this  becomes  uniform  in  speed.  For  it  is  only  the 
acceleration,  or  negatively  the  retardation,  which  is  per- 
ceived, not  the  uniform  motion.  The  arrest  of  motion  is 
again  felt  and  is  followed  by  a  transient  subjective  feeling 
of  rotation  in  the  opposite  direction,  a  negative  static  after- 
image, so  to  speak,  of  fictitious  nature.  If  the  head  is 
maintained  in  any  inclined  position,  the  direction  of  the 
rotation  is  referred  subjectively  to  the  axes  of  the  head, 
irrespective  of  the  motion  of  the  body,  and  the  reversed 
after-sensation  is  likewise  referred  to  the  axes  of  the  head 
and  moves  with  the  latter  when  the  position  of  the  head 
is  voluntarily  changed.  An  objective  evidence  of  these 
static  sensations  are  certain  reflex  movements  of  the  eyes. 
When  the  eyes  are  not  intentionally  controlled  by  the  sub- 
ject, they  are  rotated  in  a  direction  opposed  to  that  of  the 
whirling  table  with  a  speed  equal  to  that  of  the  mechani- 
cal rotation.  After  extreme  version  they  return  with  a 
sudden  jerk  to  nearly  their  initial  position,  from  which 
the  contrary  rotation  is  again  assumed.  These  move- 
ments can  also  be  felt  by  the  finger  placed  on  the  closed 
lids.  These  ocular  movements  enable  us  to  estimate  the 
relation  of  the  body  to  external  space  and  to  conform  the 
visual  sensations  with  those  furnished  by  the  static  sense. 
If  for  any  reason  the  eyes  do  not  move  at  the  same  speed 
as  the  whirling  table,  the  images  of  external  objects 
wander  over  the  retina  and  the  sensation  resulting  there- 
from is  incorrectly  interpreted  as  indicating  motion  of 
external   objects.     The  eye   movements   may  hence   be 


382  PHYSIOLOGY   OF   THE    EAR. 

called  compensatory.  The  static  sensations  as  well  as 
the  compensatory  movements  of  the  e}es  are  absent  in  a 
large  proportion  of  deaf-mutes  when  tested  by  whirling 
(James).  This  fact  supports  the  view  that  both  the  sen- 
sations and  the  ocular  movements  are  started  from  the 
semicircular  canals,  as  this  part  of  the  external  ear  is 
found  destroyed  in  many,  though  not  in  all,  deaf-mutes. 

In  birds  passive  rotation  results  in  a  swinging  motion 
of  the  mobile  neck  and  head  comparable  to  the  com- 
pensatory eye  movements  of  mammals.  This  reflex  move- 
ment is  prevented  by  extirpation  of  both  entire  labyrinths, 
provided  the  eyes  are  kept  covered,  as  otherwise  the  move- 
ments are  started  in  a  reflex  manner  by  visual  sensations. 

In  birds,  especially  pigeons,  the  large  semicircular 
canals  are  freely  accessible  and  have  hence  been  experi- 
mented upon  extensively.  The  most  decisive  observation 
made  in  this  manner  refers  to  the  occurrence  of  swinging 
motions  of  the  mobile  neck  in  the  plane  of  the  one  canal, 
which  has  been  either  divided  or  plugged.  When  the 
entire  labyrinth  is  destroyed,  the  animal  suffers  from  ex- 
treme incoordination  of  movements,  from  which  it  recovers 
largely  in  the  course  of  time.  From  a  most  painstaking 
and  varied  series  of  experiments  Ewald  has  come  to  the 
conclusion  that  the  labyrinth  exerts  a  reflex  tonus  upon 
the  entire  muscular  system,  and  that  any  movements  of 
the  body  in  any  one  plane  become  incoordinate  if  not  con- 
trolled by  the  intact  semicircular  canal  of  that  plane. 
After  destruction  of  the  labyrinth  the  animal  gradually 
learns  to  regulate  the  extent  of  its  movements  by  the 
sensations  furnished  by  the  other  senses. 

A  physical  explanation  of  the  functions  of  the  semi- 
circular canals  has  been  suggested  by  Mach,  Breuer,  and 
by  Crum  Brown,  which  seems  to  harmonize  with  all  the 
facts.  Each  semicircular  canal,  with  its  ampulla  and  the 
utricle,  forms  a  complete  hollow  ring  with  fluid  contents 
— the  endolymph.  The  three  semicircular  canals  are 
strictly  at  right  angles  to  each  other  and  hence  correspond 
to  the  three  planes  of  space.     The  semicircular  canals  of 


SEMICIRCULAR   CANALS.  383 

one  ear  are  so  mated  to  those  of  the  other  side  that  rota- 
tion of  the  head  in  any  possible  plane  involves  rotation  of 
at  least  one  pair  of  semicircular  canals  around  its  axis. 
On  account  of  the  bilateral  symmetry  of  the  two  laby- 
rinths the  direction  from  ampulla  to  semicircular  canal  is 
the  opposite  in  one  ear  from  what  it  is  in  the  other.  On 
account  of  the  inertia  and  the  mobility  of  the  endolymph 
this  fluid  lags  behind  in  any  rotation  of  a  semicircular 
canal  until  wall  and  fluid  contents  have  acquired  a 
uniform  velocity.  If,  hence,  a  semicircular  canal  is  ro- 
tated, for  instance,  with  its  ampulla  in  advance, — there 
results  either  a  motion  of  the  fluid  in  the  center  of  the 
caliber  in  the  opposite  direction,  or  at  least  an  increase 
of  pressure  in  the  ampulla  on  account  of  the  hindrance 
of  the  flow  in  the  extremely  narrow  semicircular  canal. 
These  movements  or  changes  in  the  pressure  of  the  endo- 
lymph excite  the  nerves  terminating  in  the  cilia  of  the 
maculae.  Within  a  short  time  after  rotation  has  begun 
the  endolymph  moves  with  the  same  velocity  as  its  wall, 
and  now  the  rotation  is  no  longer  perceived  if  the  eyes 
are  closed.  When,  on  the  other  hand,  the  rotation  of  the 
head  is  stopped,  the  inertia  of  the  endolymph  starts  again 
a  current  in  the  opposite  direction,  and  the  nerves  of  the 
opposite  ear  are  thrown  into  activity — hence  the  after- 
sensation  of  (fictitious)  negative  motion. 

It  is  not  merely  the  acceleration  or  retardation  of  a 
rotary  movement  which  we  can  perceive,  but  also  any 
change  of  speed  in  horizontal  or  vertical  translation.  Of 
this  we  can  assure  ourselves  by  observations,  with  closed 
eyes,  in  elevators  and  smooth-running  railroad  cars.  It 
is  not  quite  so  clear  how  the  semicircular  canals  are  in- 
fluenced by  movements  not  rotary  in  character,  but  in  all 
probability  similar  changes  of  intra-ampullary  pressure 
are  thus  created,  due  to  the  fact  that  each  ampulla  is 
continuous  on  the  one  side  with  the  very  much  narrower 
canal,  and  in  the  other  direction  with  the  much  wider 
utriculus. 

295.  The  movements  of  the  labyrinthine  endolymph 


384       ANATOMY  AND  PHYSIOLOGY  OF  THE  EAR. 

started  by  rotations  produce  the  feeling  of  dizziness,  but 
the  vehemence  necessary  for  this  sensation  varies  enor- 
mously in  different  persons,  so  that  some  are  easily  made 
dizzy,  others  only  by  extreme  rotations.  Morbid  irrita- 
tion of  the  semicircular  canals — for  instance,  when  due 
to  caries — is  hence  accompanied  by  characteristic  vertigo. 
The  connection  with  the  semicircular  canals  explains  the 
frequent  occurrence  of  dizziness  in  the  course  of  various 
forms  of  ear  disease.  Lesions  of  the  labyrinth  are  espe- 
cially characterized  by  vertigo  and  unsteadiness,  which 
persist  until  the  patient  has  learned  to  depend  entirely  on 
the  evidence  of  his  other  senses.  In  deaf-mutes  with 
destroyed  semicircular  canals  dizziness  can  no  longer  be 
produced  by  rotation.  These  patients  have,  on  the  other 
hand,  the  disadvantage  that  they  cannot  learn  to  perform 
bodily  movements  requiring  an  accurate  sense  of  equi- 
librium, especially  while  closing  their  eyes. 

296.  The  ordinary  sensibility  of  the  ear  is  very  acute. 
Even  the  most  delicate  touch  of  the  skin  of  the  meatus, 
the  drumhead,  or  the  exposed  tympanic  walls  with  a 
blunt  probe  is  painful.  Mechanical  irritation  of  the 
lining  of  the  meatus  is  apt  to  cause  a  characteristic 
reflex — viz.,  fits  of  coughing. 

The  gross  anatomy  of  the  ear  was  mainly  developed  by  the 
great  anatomists  of  the  sixteenth  centur3-,  Vesalius,  Eustachius, 
and  Fallopia,  At  the  end  of  the  seventeenth  century  Valsalva 
added  many  details.  Since  that  time  the  anatomy  of  the  ear  has 
been  completed  gradually  by  numerous  contributors.  Good  de- 
tailed accounts  can  be  found  in  all  larger  treatises  on  systematic 
anatomy.  In  otologic  literature  the  fullest  descriptions  are  in 
Schwartze's  Handbuch  der  Ohrenheilkunde,  1892,  and  in  Politzer's 
Ohrenheilkunde,  fourth  edition,  1901  (English  translation  by 
Dodd,  1892). 

Politzer  has  also  written  an  indispensable  guide  for  the  dis- 
section of  the  ear,  Zergliederung  des  menschlichen  Gehororgans, 
1889.  The  physiology  of  hearing  was  almost  wholly  the  work  of 
Helmholtz,  and  is  detailed  in  his  Lehre  von  den  Tonempfindun- 
gen,  1870  (English  translation  by  Ellis,  Sensation  ojf  Tone,  etc., 
second  edition,  1885). 

The  semicircular  canals  have  been  extensively  experimented 


PHYSIOLOGY   OF   THE    EAR.  385 

Upon  since  the  days  of  Flourens.  Goltz  was  the  first  to  charac- 
terize them  as  the  organ  of  a  special  sense  of  equilibrium.  The 
most  extensive  researches  on  the  subject  are  those  by  Ewald  in 
his  Phys.  Untersuchungen  uber  d.  Endorgan  des  Nervus  Octavus, 
1892.  The  observations  on  man  made  on  the  whirling  table  by 
Mach,  Breuer,  and  by  Crum  Brown  are  excellently  described  by 
the  latter  in  a  lecture  in  Nature,  June  20,  1895. 
25 


CHAPTER    XXXI. 

GENERAL  ETIOLOGY  OF  EAR  DISEASE. 

397.  Notwithstanding  the  deep  protected  location  of 
the  organ  of  hearing,  it  is  very  frequently  affected  by 
disease.  According  to  various  statistics,  the  external  ear 
is  involved  in  25  per  cent,  the  middle  ear  in  70  per  cent, 
and  the  internal  ear  and  nerve  in  about  5  per  cent,  of  all 
ear  patients.  Traumatism  plays  but  a  small  role  in  the 
production  of  ear  disease.  Blows  may  lead  to  bloody 
effusions  in  the  auricle  with  subsequent  deformity  or  to 
rupture  of  the  drum-head.  Foreign  bodies  in  the  meatus, 
a  frequent  accident  in  childhood,  cause  serious  mischief 
only  if  violence — for  instance,  during  attempts  at  extrac- 
tion— wounds  the  meatus  or  drumhead  and  opens  the 
gate  to  infection.  Slight  traumatism  combined  with 
subsequent  infection  is  a  common  result  of  scratching  the 
meatus  with  pins,  hair-pins,  and  other  articles.  The 
thin  skin  is  very  easily  abraded,  and,  being  covered 
with  dust  containing  living  germs,  furuncles,  diffuse 
inflammation  of  the  meatus,  and  even  extension  to  the 
middle  ear  are  not  an  uncommon  penalty  for  this  habit. 
Diving  under  water  accounts  for  some  ear  disease, 
especially  when  certain  unfavorable  conditions  preexist. 
Wax  present  in  excess  will  swell  when  wetted  and  may 
now  occlude  the  meatus.  A  former  cured  suppuration 
may  be  rekindled  if  a  perforation  of  the  drumhead 
permits  the  water  to  reach  the  middle  ear.  Cold  water 
pressing  against  the  intact  membrana  tympani  some- 
times, though  rarely,  starts  the  extension  of  a  catarrhal 
process  from  the  pharynx  to  the  ear.  All  this  can  be 
guarded  against  by  a  plug  of  ordinary  non- absorbing 
cotton  in  the  ear  while  bathing. 

386 


GENERAL    ETIOLOGY    OF    EAR    DISEASE.  387 

Less  common,  but  more  serious,  is  acute  otitis  media 
due  to  the  entrance  of  water  through  the  Eustachian 
tubes  as  tlie  result  of  swallowing  under  water. 

^98.  The  majority  of  affections  of  the  middle  ear, 
excepting  tubercular  otitis  media  and  sclerosis,  originate 
from  extension  of  disease  in  the  nose  or  pharynx.  In  a 
broad  way  it  may  be  stated  that  all  cases  of  catarrhal  or 
purulent  middle-ear  disease  are  preceded  by  nasopharyn- 
geal lesions,  except  that  some  of  the  eruptive  fevers 
(measles  and  scarlatina)  may  involve  the  mucous  mem- 
brane of  the  middle  ear  and  of  the  nasopharynx  at  the 
same  time.  In  all  the  various  forms  of  inflammation  of 
the  middle  ear  nasopharyngeal  lesions  are  either  present 
or  were  present  at  the  start.  In  some  instances  of  pro- 
liferative and  of  serous  catarrh  of  the  middle  ear  the 
dependence  on  the  lesions  in  the  air-passages  can  be 
shown  by  the  successful  results  of  nasopharyngeal  treat- 
ment. This  success  is,  however,  not  always  obtained. 
Suppuration  of  the  middle  ear,  on  the  other  hand,  after 
it  is  once  started,  continues  independently  of  the  condi- 
tion in  the  nasopharynx,  and  is  hence  not  cured  by  their 
successful  removal.  But  when  the  history  shows  fre- 
quent recurrences  of  otitic  suppuration  after  natural  or 
surgical  cure,  the  benefit  of  proper  nasopharyngeal  treat- 
ment is  easily  demonstrable.  The  nasopharyngeal  origin 
of  ear  disease  is  often  plainly  suggested  in  one-sided 
affections  by  the  limitation  of  the  ear  disease  to  the  side 
of  the  nasal  stenosis. 

The  etiologic  relation  of  the  different  forms  of  nasal 
and  pharyngeal  disease  to  aural  affections  can  be  sum- 
marized as  follows  :  Ordinary  acute  coryza  and  pharyn- 
gitis or  tonsillitis  do  not  often  cause  ear  trouble  if  the 
respiratory  passages  had  hitherto  been  structurally  nor- 
mal. The  liability  to  involvement  of  the  ear  increases, 
however,  with  the  degree  of  previous  structural  anomaly, 
especially  if  of  an  obstructive  character.  In  children 
the  most  important  predisposing  lesion  is  enlargement  of 
the  pharyngeal  tonsil  and,  to  a  much  less  extent,  hyper- 


388  GENERAL    ETIOLOGY    OF    EAR    DISEASE. 

trophy  of  the  faucial  tonsils.  In  adults  the  adenoid 
overgrowth  plays  a  minor  role  in  frequency  and  import- 
ance, while  any  form  of  nasal  stenosis  is  an  important 
pathogenic  factor.  As  long  as  the  obstructive  lesions  are 
not  accompanied  by  acute  or  subacute  inflammation  they 
do  not  lead  to  any  acute  ear  disease.  But  it  is  their 
presence  which  renders  any  complicating  acute  nasal  or 
pharyngeal  inflammation  a  menace  to  the  ear.  The  form 
of  ear  disease  resulting  from  these  conditions  are  reten- 
tion of  wax  in  the  meatus,  purulent  otitis,  or  serous 
catarrh  of  the  middle  ear.  In  children  the  acute  ear 
involvement  is  usually  the  purulent  form.  After  the  age 
of  puberty  serous  catarrh  is  more  likely  to  occur  than 
purulent  otitis.  In  cases  of  one-sided  nasal  stenosis  the 
ear  of  the  same  side  is  much  more  likely  to  suffer  than 
its  mate.  The  danger  of  nasopharyngeal  inflammation 
as  regards  the  ear  is  much  greater  when  the  respiratory 
lesions  are  part  of  some  general  disease,  as  measles, 
scarlet  fever,  and  especially  influenza,  than  in  affections 
purely  localized  in  the  nose  and  throat.  The  danger 
from  diphtheria  is  about  the  same  as  from  ordinary 
pharyngitis,  at  least  numerically,  although  the  ear  dis- 
ease when  it  does  follow  diphtheria  is  likely  to  be  more 
severe. 

Subacute  inflammatory  processes  in  the  nasopharynx 
of  children  with  enlarged  pharyngeal  tonsil  result  in 
catarrh  of  the  Eustachian  tube,  an  affection  which  may 
be  said  to  have  a  subacute  course. 

Purely  chronic  inflammatory  conditions  in  the  nose 
and  throat  lead  to  the  adhesive  form  of  middle-ear 
catarrh,  especially  when  the  nasopharyngeal  condition 
tends  toward  hypertrophy.  A  material  determining 
factor  in  the  extension  of  the  hyperplastic  process  to  the 
ear  is  the  narrowing  of  the  nasal  passage  by  septum  ir- 
regularities. The  influence  of  nasal  stenosis  is  generally 
upon  the  ear  of  the  same  side,  but  in  the  chronic  and 
insidious  form  of  disease  there  are  occasional  exceptions 
to  the  rule.     Acute  or  subacute  catarrhal  exacerbations 


GENERAL    ETIOLOGY    OF    EAR    DISEASE.  389 

in  the  course  of  hypertrophic  rhinitis  usually  intensify 
the  middle-ear  affection  by  corresponding  exacerbations 
of  the  ear  disease. 

Diseases  of  the  middle  ear  are  thus  not  only  an  exten- 
sion of  nasopharyngeal  processes,  but,  on  the  whole,  also 
a  copy  of  the  type  of  the  disease  in  the  air-passages. 
The  ear  disease  may,  however,  persist  after  the  original 
disturbance  in  the  nose  or  pharynx  has  ceased.  More- 
over, the  course  of  the  ear  disease  may  become  com- 
plicated by  secondary  changes,  such  as  adhesions  in 
catarrhal  otitis  and  bone  affections  in  the  purulent  form. 

299.  The  microbes  causing  purulent  inflammation  of 
the  middle  ear  have  been  identified  as  the  pneumococcus, 
streptococcus,  staphylococcus,  bacillus  pneumoniae  (Fried- 
lander),  bacillus  pyocyaneus,  and  exceptionally  a  few 
others,  sometimes  in  combination.  In  serous  catarrh  of 
the  ear  the  same  bacteria  have  been  found  in  a  small  num- 
ber of  observations.  Whether  the  etiologic  difference 
between  purulent  and  serous  otitis  depends  on  a  difference 
in  the  number  of  microbes  or  on  a  different  mode  of  re- 
action of  the  tissues  in  different  subjects  is  unknown. 
Clinically  the  two  diseases  are  separate  and  distinct,  and 
the  occurrence  of  one  renders  the  future  appearance  of 
the  other  very  unlikely,  even  in  the  ear  of  the  other 
side. 

Pathogenic  microbes  can  reach  the  middle  ear  through 
the  Eustachian  tube — for  instance,  during  violent  efforts 
of  coughing  or  blowing  the  nose.  The  most  striking 
demonstration  of  this  mode  of  pyogenic  infection  is  the 
otitis  following  within  eight  to  twenty-four  hours  after 
the  entrance  of  water  from  a  nasal  douche  into  the  tube. 
In  most  cases,  however,  it  is  probably  less  a  transport  of 
infectious  material  through  the  Eustachian  passage  than 
a  growth  of  the  parasite  in  the  mucous  membrane  or  the 
lymph-channels  of  the  tube  which  leads  to  otitic  infec- 
tion. Yet  the  pharyngeal  end  of  the  tube  is  not  rarely 
normal  during  life  or  at  the  autopsy  in  acute  suppurative 
otitis. 


390  GENERAL    ETIOLOGY    OF    EAR    DISEASE. 

Whether  the  plastic  or  hypertrophic  form  of  disease 
depends  on  the  presence  of  parasites  is  not  known,  either 
in  the  case  of  the  ear  or  of  the  respiratory  lining.  The 
process  in  these  cases  is  a  continuous  one  from  the  pharynx 
through  the  tube  to  the  tympanic  cavity. 

300.  "Taking  cold"  is  an  important  factor  in  the 
causation  and  perpetuation  of  middle-ear  disease,  espe- 
cially in  serous  catarrh  and  exacerbations  in  the  course  of 
hypertrophic  otitis  media.  The  mechanism  of  "  taking 
cold  "  and  the  known  facts  concerning  it  have  been  dis- 
cussed in  the  chapter  on  Etiology  of  Nasal  Diseases  (Ti  13). 
The  doubt  whether  chilling  of  the  body  can  start  an  in- 
flammator>'  process  in  a  hitherto  normal  structure  does 
not  apply  in  the  case  of  the  ear,  since  its  involvement 
under  such  circumstances  means  only  the  extension  of 
preexisting  nasopharyngeal  disease.  A  clear  history  of 
"cold  "  as  an  etiologic  factor  can  be  obtained  only  in  a 
small  number  of  instances,  but  in  some  of  them  its  in- 
fluence seems  well  supported  by  the  evidence.  There 
certainly  can  be  no  doubt  that  careless  exposure  and 
insufficient  protection  exert  an  unfavorable  effect  upon 
the  course  of  any  inflammatory  affection  of  the  middle 
ear.  Habitually  cold  feet  should  receive  attention  in 
connection  with  any  ear  disease  (compare  1  13). 

301.  The  eruptive  fevers  are  responsible  for  a  large 
proportion  of  ear  diseases.  In  measles  an  inflammatory 
lesion  with  exudation  has  been  found  in  every  fatal  case 
examined,  while  in  scarlet  fever  we  know  at  least  clini- 
cally that  involvement  of  the  ear  is  very  common.  The 
first  lesion  in  eruptive  fevers  is  probably  the  specific 
exanthema  in  the  mucous  membrane  of  the  Eustachian 
tube  and  middle  ear,  coincident  with  the  eruption  in  the 
pharynx  and  perhaps  prior  to  the  cutaneous  manifesta- 
tion. But  this  specific  lesion  follows  a  benign  course 
and  is  not  revealed  clinically  at  all,  unless  complicated 
by  secondary  infection  with  pyogenic  microbes.  The 
probability  of  this  complication  increases  with  the  degree 
of  previous  structural  anomaly  in  the  nose  and  pharynx 


GENERAL    ETIOLOGY    OF    EAR    DISEASE.  39 1 

and  the  intensity  of  their  involvement  by  the  eruptive 
fever.  Diphtheria  does  not  extend  to  the  ear  often,  but 
when  it  does,  the  disease  is  of  a  severe  type,  though 
rarely  due  to  the  bacillus  of  diphtheria  itself  Influenza 
may  cause  a  primary  otitis  media,  of  a  hemorrhagic,  but 
generally  not  purulent,  character.  Within  the  past  few 
years  this  form  of  influenza  otitis  has  become  less  com- 
mon, while  the  ordinary  purulent  otitis  secondary  to  a 
purulent  influenza  rhinitis  is  seen  oftener.  A  large 
number  of  children  with  purulent  otitis  are  scrofulous. 
Whether  this  disease  itself — viz.,  the  poisoning  of  the 
system  from  some  minute  tubercular  focus  in  lymph- 
glands — reduces  the  resisting  power  to  pyogenic  infection 
is  not  definitely  proven,  though  probable.  The  direct 
cause,  however,  of  the  purulent  otitis  is  the  enlargement 
of  the  pharyngeal  tonsil,  together  with  the  frequent 
spells  of  acute  and  subacute  nasal  inflammation  common 
in  scrofulous  children.  Eczema  of  the  face  or  scalp  is 
likewise  a  frequent  manifestation  in  scrofula,  and  its  ex- 
tension to  the  auricle  is,  therefore,  not  uncommon. 

Extension  of  pyogenic  infection  from  the  middle  ear 
into  the  mastoid  process  or  into  the  bone  in  general  is 
favored  by  any  impoverished  state  of  nutrition — for  in- 
stance, diabetes. 

Non-suppurative  ear  disease,  especially  the  proliferative 
form,  is  not  a  rare  sequel  to  typhoid  fever.  Relatively 
often  I  have  seen  post-typhoid  trouble  in  the  form  of 
plastic  middle-ear  disease,  often  one-sided,  of  rapid  prog- 
ress for  a  number  of  months,  but  afterward  permanently 
stationary.  Diseases  of  the  middle  ear,  while  not  directly 
caused,  are  usually  unfavorably  influenced  by  any  mal- 
nutrition, as  anemia  and  digestive  disturbances,  exactly 
like  the  nasal  and  pharyngeal  aflections  starting  them 
(compare  1  i6  and  1  17). 

302.  Morbid  change  in  the  internal  ear  and  nerve-ends 
may  result  from  various  intracranial  diseases,  first  among 
which  ranks  cerebrospinal  meningitis.  Atrophic  proc- 
esses in  the  auditory  nerve  occur  in  the  course  of  tabes. 


392  GENERAL    ETIOLOGY    OF    EAR    DISEASE. 

Severe  aflfections  of  the  internal  ear  are  also  due  in  limited 
number  to  scarlet  fever,  mumps,  typhoid  fever,  syphilis, 
especially  the  inherited  form.  Sometimes  they  coincide 
with  severe  forms  of  digestive  disturbances.  Nerve- 
deafness  occurs  in  a  small  but  noticeable  proportion  of 
patients  with  pigment  degeneration  of  the  retina.  A 
curious  observation,  repeatedly  noted,  is  that  among 
albinotic  (white)  cats  there   are  very  many  deaf-mutes. 

Direct  injury  to  the  labyrinth  has  been  observed  after 
large  doses  of  quinin  and  in  few  very  rare  instances  from 
salicylate  of  sodium.  Affections  of  the  teeth  may  in- 
fluence the  ear.  A  mild  purulent  otitis  apparently  trace- 
able to  a  coryza  coincides  quite  often  with  teething  in 
children.  Caries  of  any  of  the  rear  teeth  or  even  the 
normal  eruption  of  wisdom-teeth  is  sometimes  attended 
by  neuralgic  pains  referred  to  the  ear,  the  origin  of  which 
is  found  only  after  a  definite  search. 

303.  The  surroundings  and  occupation  may  have  an 
influence  upon  the  ears.  Continuous  loud  noises,  like 
heavy  hammering,  impair  the  hearing  gradually  by  set- 
ting up  a  sclerotic  process  in  the  internal  ear.  Boiler- 
makers, workmen  in  machine  shops,  and,  to  a  less  extent, 
railroad  engineers  and  firemen,  show  a  large  percentage 
of  cases  of  progressive  nerv^ous  deafness.  The  danger  is 
greater  to  those  who  enter  such  employment  with  some 
previous  anomaly  in  the  middle  ear.  Artillery  men  are 
somewhat  subject  to  the  same  danger,  besides  suffering 
at  times  from  rupture  of  the  drumhead  in  consequence  of 
detonations.  Opening  the  mouth  to  facilitate  equalization 
of  air-pressure  through  the  Eustachian  tubes  and  wearing 
cotton  plugs  in  the  ear  are  well-known  protective  meas- 
ures among  the  artillery.  Whether  the  cotton  plug 
would  also  protect  boilermakers  and  others  exposed  to 
loud  din  is  probable,  but  has  not  been  tested  suflSciently. 
Mechanical  accidents  to  the  drumhead  may  occur  too  in 
workmen  working  in  pneumatic  caissons  in  compressed 
air  under  water,  as  in  bridge-building.  It  is  not  the  ab- 
normal air-pressure  by  itself,   but  rather  a  too  sudden 


GENERAL    ETIOLOGY    OF    EAR    DISEASE.  393 

change  in  the  pressure,  which,  when  not  quickly  com- 
pensated through  Eustachian  ventilation,  may  cause 
rupture.  Too  sudden  a  diminution  of  such  extreme  air- 
pressure  leads  to  liberation  of  air-bubbles  in  the  capil- 
laries, often  with  minute  hemorrhages,  and  this  accident 
has  occurred  as  well  as  in  the  labyrinth  of  the  ear  as  in 
the  central  nervous  system. 

304.  Heredity  is  an  important  factor  in  the  predis- 
position to  ear  disease.  The  liability  to  aural  afifections 
is  decidedly  increased  by  the  history  of  disease  in  the 
parents  or  near  relatives.  While  plastic  and  sclerotic 
middle-ear  processes  are  the  commonest  forms  observed 
in  predisposed  families,  still  the  individual  under  the 
influence  of  a  bad  heredity  may  acquire  any  type  of  ear 
disease.  The  intermarriage  of  deaf-mutes  leads  to  a 
large  proportion  of  deaf-mutes  in  the  offspring,  but  still 
with  a  preponderance  of  normal  children. 


CHAPTER   XXXII. 

SUBJECTIVE     SYMPTOMS    AND    METHODS    OF    EX- 
AMINATION AND  TREATMENT  IN  EAR   DISEASES. 

305.  Pain  in  the  form  of  more  or  less  severe  earacne  is 
produced  by  acute  inflammation  in  either  the  meatus  or 
the  middle  ear,  and  especially  in  the  mastoid  bone.  Its 
severity  and  duration  are  proportionate  to  the  intensity 
of  the  inflammatory  processes.  Chronic  disease  does  not 
cause  pain.  Subacute  catarrh  of  the  Eustachian  tube 
is  sometimes  productive  of  earache  in  children.  Acute 
pharyngeal  lesions  near  the  Eustachian  orifice,  such  as 
ulcers  near  the  lateral  recesses  of  the  pharynx  and  wounds 
of  the  upper  part  of  the  tonsil,  give  rise  to  sharp  pain 
referred  to  the  ear.  Erupting  wisdom-teeth  and  disease 
of  any  tooth  back  of  the  bicuspids  can  induce  otalgia — 
neuralgic  pains  in  the  ear. 

Itching  in  the  ears  is  at  times  a  source  of  great  distress 
to  nervous  people.  It  may  be  due  to  an  easily  overlooked 
area  of  slight  eczema  in  the  meatus,  or,  on  the  other 
hand,  to  venous  congestion  around  the  Eustachian  orifice 
in  neurasthenics  with  irritable  nose.  It  is  often  very 
annoying  in  hay  fever. 

A  full  or  "  stopped-up  "  feeling  in  the  ears  results  from 
occlusion  of  the  meatus  by  wax,  especially  if  the  latter 
presses  on  the  drumhead.  Furuncles  and  diffuse  inflam- 
mation of  the  meatus  cause  stuflEiness  in  proportion  to 
the  swelling  present.  Stuffiness  is  characteristic,  too,  of 
serous  catarrh,  while  in  the  plastic  form  of  middle-ear 
disease  it  is  a  less  constant  or  prominent  symptom.  It  is, 
of  course,  present  during  the  acute  stage  of  purulent 
otitis. 

In  connection  with  the  "stuffy"  feeling  patients 
mention  the  subjective  want  of  resonance  of  their  own 
394 


VERTIGO.  395 

voice.  It  sounds  muffled  to  the  patient,  even  though  his 
hearing  for  external  sounds  may  not  have  suffered  ap- 
preciably. A  similar  muffling  of  the  sound  is  often 
noticed,  especially  in  one-sided  disease,  when  a  noise  is 
produced  by  scratching  the  region  around  the  ear.  Quite 
different  from  this  subjective  muffling  of  the  voice  is 
the  excessive  resonance,  which  has  been  termed  "au- 
tophony."  It  is  complained  of  by  patients  without  ear 
disease,  but  whose  Eustachian  tubes  presumably  gape  to 
an  abnormal  extent  on  account  of  inflammatory  rigidity 
of  their  walls  or  perhaps  from  wasting  of  the  cushion  of 
fat  in  the  external  wall  of  the  tube. 

Vertigo  varying  from  momentary  slight  dizziness  to  a 
more  or  less  continuous  feeling  of  insecurity  may  result 
from  various  ear  affections.  Pressure  of  wax  against  the 
drumhead,  syringing  with  cold  water  or  with  too  much 
force,  especially  when  there  is  disease  of  the  attic,  can 
cause  it.  Persistent  dizziness  is  a  grave  symptom  in 
suppuration  of  the  middle  ear.  Disease  limited  to  the 
tympanic  cavity  without  retention  of  pus  in  the  attic 
does  not  provoke  vertigo  unless  there  is  caries  of  the 
labyrinth.  This  symptom,  however,  is  characteristic  of 
any  involvement  of  the  semicircular  canals,  whether  the 
disease  be  primarily  labyrinthine  or  due  to  extension  to 
the  internal  ear.  Severe  ear  vertigo  leads  to  nausea  and 
vomiting,  staggering,  or  even  the  inability  to  rise  from 
the  recumbent  position. 

306.  Noises  and  ringing  in  the  ear,  technically  termed 
tinnitus^  are  a  serious  annoyance  to  many  ear  patients. 
Some  neurasthenics  have  been  driven  by  it  to  suicide. 
Wax  in  the  meatus  may  cause  a  roaring  sound.  In  sup- 
purative otitis  tinnitus  is  usually  absent,  sometimes,  how- 
ever, following  later  by  reason  of  intratympanic  adhesions. 
In  serous  catarrh  it  is  a  minor  symptom.  But  the  hyper- 
trophic form  of  middle-ear  disease — and  to  a  much  less 
frequent  extent  sclerosis — is  characterized  by  subjective 
noises,  sometimes  as  the  earliest  symptom.  Disease  of 
the  internal  ear  is  not  always  accompanied  by  subjective 


396  SUBJECTIVE    SYMPTOMS    IN    EAR    DISEASES. 

sounds,  though  mostly  so.  The  aura  of  epilepsy  is  some- 
times an  auditory  illusion.  Tinnitus  may  sound  like 
roaring,  singing  of  birds,  ringing  of  bells,  whistling,  or 
hissing  of  escaping  steam.  Quite  often  it  is  a  pulsating 
noise,  sometimes  a  musical  sound  or  a  changing  din.  It 
may  be  heard  only  in  the  stillness  of  the  night,  or  it  may 
be  so  loud  as  to  drown  continuously  all  external  sounds. 
Neither  the  anatomic  lesions  causing  tinnitus  nor  its 
physiologic  mechanism  are  fully  understood.  It  must, 
of  course,  be  due  to  irritation  of  the  intralabyrinthine 
nerve-ends.  Pulsating  sounds  are  due  to  the  pulsation 
of  the  arterioles  somewhere  in  the  ear,  and  are  often  con- 
trolled by  absolute  rest,  or  transiently  by  compression  of 
the  carotid  artery,  but  are  aggravated  by  any  exertion  or 
excitement.  In  very  rare  instances  pulsating  noises  have 
been  caused  by  an  aneurysm  of  smaller  intracranial  or 
other  adjoining  blood-vessels.  Snapping  sounds  which 
are  really  objective  and  can  be  heard  by  auscultation 
through  a  tube  from  the  meatus  to  the  listener's  ear  are 
occasionally  due  to  spasms  of  the  tensor  tympani  muscle; 
oftener,  however,  to  contraction  of  the  tensor  palati  mus- 
cle, which  some  people  can  control  voluntarily.  Instances 
have  been  known  in  which  a  nocturnal  ticking-  was  com- 
plained  of,  due  to  the  watch  under  the  pillow.  Diplacusis 
is  the  term  applied  to  the  wrong  "tuning"  of  one  ear, 
occasionally  observed  by  musical  patients  in  the  course  of 
a  mild  middle-ear  catarrh  with  secretion.  All  notes  sound 
a  trifle,  perhaps  half  a  tone,  too  high  or  too  low  as  com- 
pared with  the  normal  ear.  It  depends  probably  on  some 
circulatory  disturbance  or  slight  effusion  in  the  cochlea. 

307*  l^he  hearing  acuity  is  reduced  more  or  less  by  all 
diseases  of  the  ear  except  minor  affections  of  the  meatus, 
like  small  furuncles  or  slight  eczema.  Yet  this  may  not 
be  the  patient's  reason  for  seeking  advice,  either  because 
the  deafness  is  scarcely  noticeable  in  the  beginning  of  an 
affection  or  because  it  has  been  stationary  so  long  that  he  is 
accustomed  to  it,  or  because  it  is  overshadowed  by  other 
symptoms.     In  most   instances  of  disease  of  the  sound- 


THE    HEARING    ACUITY    IN    EAR    DISEASES.  39/ 

conducting  parts  the  hearing  is  noticeably  improved  by 
external  noises,  like  the  rattling  of  railroad  cars,  which 
deafen  normal  persons.  In  disease  of  the  labyrinth,  on 
the  other  hand,  noisy  surroundings  reduce  the  patient's 
hearing  power. 

The  hearing  acuity  cannot  be  measured  at  present  with 
any  scientific  accuracy.  We  would  require  for  this  pur- 
pose a  device  furnishing  pure  tones — without  overtones — 
throughout  the  entire  auditory  range,  the  intensity  of 
which  could  be  measured  and  regulated  with  mechanical 
precision.  Despite  numerous  efforts  to  utilize  tuning- 
forks,  electric  mechanisms,  telephone,  or  phonograph  for 
this  purpose,  no  measuring  contrivance  has  been  devised, 
the  utility  of  which  is  at  all  proportionate  to  its  compli- 
cated mechanism  or  cost.  It  is  very  easy  to  obtain  a 
single  tone  of  fairly  constant  or  measurable  intensity,  but 
the  requisite  multiplication  of  notes,  especially  of  pure 
tones  without  overtones,  makes  any  such  device  im- 
practicable. Tuning-forks  or  steel  rods  struck  by  a  spring 
hammer  of  constant  force  (Politzer's  acumeter)  serve  very 
well  as  a  source  of  a  single  tone  of  constant  pitch  and 
intensity,  the  audibility  of  which  depends  on  the  distance 
from  the  ear.  But  they  have  no  advantage  over  the  tick- 
ing of  a  watch.  If  the  distance  at  which  the  individual 
watch  is  heard  b)^  the  normal  ear  is  stated  as  the  denomi- 
nator (d),  and  the  distance   at   which  the  patient's   ear 

hears  it  as  the  numerator  (n),  the  resulting  fraction  J  is  a 

convenient  though  not  physically  accurate  expression 
of  the  patient's  hearing  ability.  But  this  measurement 
refers  only  to  the  high  tones  of  the  watch  and  is  not  indi- 
cative of  the  hearing  ability  for  other  tones.  Since  the 
hearing  power  may  suffer  unequally  for  different  parts  of 
the  scale,  it  would  be  desirable  to  have  some  instrument 
which  could  supply  tones  throughout  the  entire  range  of 
audition.  Still  the  watch  gives  a  serviceable  method  of 
measuring  the  effect  of  treatment  upon  the  hearing  power. 
The  hearing  distance  should  be  noted  while  approaching, 


398  SUBJECTIVE   SYMPTOMS    IN    EAR    DISEASES. 

rather  than  while  receding  from  the  watch,  since  in  the 
latter  case  it  is  more  difficult  to  state  when  the  audible 
tick  ceases.  Young  children  do  not,  as  a  rule,  give 
trustworthy  answers  when  tested  with  the  watch. 

The  most  serviceable  method  of  measuring  the  hearing 
acuity  for  practical  purposes  is  the  voice.  Monosyllables 
are  repeated  louder  or  nearer  until  the  patient  repeats  the 
word  correctly.  In  order  to  avoid  guess-work,  the  patient 
must  not  watch  the  lips,  and  single  syllables  should  be 
pronounced  without  prearranged  order.  Different  con- 
sonants offer  variable  difficulty  of  perception,  especially 
in  ankylosis  of  the  foot-plate  of  the  stirrup  ^nd  in  affec- 
tions of  the  internal  ear.  Striking  confusion  in  the  re- 
peated words  raises  hence  the  suspicion  of  such  lesions. 
The  examiner  must  learn  to  speak  with  approximately  con- 
stant loudness  of  voice  (either  whisper  or  ordinary  tone), 
and  test  the  hearing  power  b)'  changing  his  distance  from 
the  ear.  The  range  of  the  voice-test  can  be  increased — 
for  instance,  in  small  rooms — by  learning  to  modulate 
the  voice  with  constancy,  thus  speaking  first  in  a  faint 
whisper,  then  in  a  medium  loud  whisper,  and  finally  a 
loud  whisper,  and  if  this  does  not  suffice,  repeating  in 
ordinary  voice  faintly,  in  average  tone,  or  loudly.  One 
should,  of  course,  be  familiar  with  the  normal  hearing 
distance  in  a  given  room  and  under  given  surroundings 
(street  noise).  A  fairly  accurate  record  of  a  patient's 
hearing  power  can  thus  be  kept  and  changes  noted.  But 
a  comparison  of  the  records  of  different  examiners  in 
regard  to  changes  in  the  hearing  acuity  is  scarcely  as 
accurate  as  an  intelligent  patient's  personal  opinion,  on 
account  of  the  difference  in  voices. 

308.  The  range  of  audition  can  be  tested  by  means  of 
Bezold's  continuous  tone-series.  It  consists  of  a  series  of 
tuning-forks,  each  of  which  can  change  its  pitch  within 
the  limits  of  nearly  one  octave  by  the  shifting  of  movable 
clamps.  The  middle  register  is  tested  with  two  organ- 
pipes  with  movable  stops,  while  the  upper  end  of  the 
scale  is  furnished  by  the  Galton  whistle.    Researches  with 


THE    HEARING    ACUITY    IN    EAR    DISEASES.  399 

the  continuous  tone-series  have  shown  that  the  remnant 
of  hearing  power  in  affections  of  the  internal  ear  is  some- 
times represented  by  a  small  "island"  in  the  middle  of 
the  scale  or  may  comprise  a  fair  part  of  the  lower  end  of 
the  scale,  with  gaps  for  certain  tones. 

For  most  clinical  purposes  it  suffices  to  test  the  hearing 
power  for  the  lower  tones  by  means  of  a  heavy  tuning- 
fork  and  for  the  upper  end  of  the  scale  by  the  Galton 
whistle.  A  large  tuning-fork  with  a  movable  clamp, 
giving  from  64  to  128  vibrations  a  second  (C-c),  is  com- 
monly used.  In  affections  of  the  sound-conducting  ap- 
paratus (membrana  tympani  and  chain  of  ossicles)  this  is 
not  so  readily  heard  through  the  air  as  higher  tones, 
while  its  perception   by  bone-conduction    is  normal  or 


Fig.  1 14. — Gallon's  whistle  with  rubber  bulb.  The  pipe  below  the  opening 
is  filled  by  a  plunger  advanced  or  withdrawn  by  a  screw,  each  turn  being  shown 
by  the  scale  upon  the  enlarged  tube,  and  its  tenths  by  that  on  the  revolving 
collar.  It  gives  an  audible  sound  from  0.5  (theoretically,  84,000  v.  s.)  to  10  or 
12  (4200  or  3500). 

slightly  intensified.  The  Galton  whistle,  a  miniature 
stopped  organ-pipe,  varies  its  pitch  by  sliding  the  stop 
(Fig.  114).  Its  range  is  from  6000  to  nearly  50,000  vibra- 
tions a  second.  On  some  of  the  more  recent  patterns  the 
pitch  is  approximately  marked,  but  this  is  not  absolutely 
necessary  if  the  whistle  is  tested  by  comparison  with  a  nor- 
mal ear.  The  perception  of  the  highest  notes  is  not 
affected  by  any  lesion  interfering  with  sound-conduction, 
but  markedly  so  by  disease  of  the  labyrinth.  The  shrill 
tone  of  the  Galton  whistle  is  conducted  so  much  more 
readily  through  the  cranial  bones  than  through  the  air 
that  stoppage  of  the  ear  by  a  plug  scarcely  interferes 
with  its  perception.  It  cannot,  hence,  detect  one-sided 
disease  with  certainty. 


400 


SUBJECTIVE   SYMPTOMS    IN    EAR    DISEASES. 


309.  The  precise  site  of  lesions  in  the  ear  is  determined 
by  certain  differences  between  the  air-conduction  (A.  C) 
and  the  bone-conduction  (B.  C.)  of  sounds  in  different 
forms  of  disease  (compare  1  293).  The  tests  are  made 
with  tuning-forks,  mainly  the  c^,  of  512  vibrations  a 
second,  and  the  c  of  128  vibrations  (Fig.  115).  In  Rinne's 
test  the  fork,  while  sounding,  is  held  near  the  meatus, 
and  its  loudness  is  compared  with  the  tone  the  patient 
hears  on  placing  the  stem  firmly  upon  the  mastoid  bone. 
Normally  this  sound  is  much  louder  by  air-conduction, 
and  hence  heard  longer  than  when  conducted  through  the 


Fig.  1 15 . — Tuning-forks. 


mastoid  bone,  and  Rinne's  test  is  called  positive  (Rinne  +). 
All  lesions  which  interfere  with  the  conveyance  of  sound 
through  the  drumhead  and  ossicles  diminish  the  sub- 
jective loudness  in  the  case  of  A.  C. ,  and  hence  shorten 
the  time  during  which  the  tone  of  the  subsiding  tuning- 
fork  is  heard.  Bone-conduction  is  not  thereby  diminished, 
sometimes  even  moderately  intensified.  This  is  especially 
true  of  the  lower  tones.  Hence  the  test  with  the  forks 
C  or  c  is  the  most  definite.  After  the  time  of  perception 
by  A.  C.  and  by  B.  C. — or  at  least  their  ratio — has  been 
determined  with  a  watch,  it  is  easy  to  tell  whether  the 


SUBJECTIVE   SYMPTOMS    IN    EAR    DISEASES.  40I 

period  of  A.  C.  is  shortened  in  the  Rinne  test.  In  ex- 
treme cases  the  result  is  reversed — the  fork  is  heard  longer 
and  louder  through  the  bone  than  through  the  air  (Rinne 
negative  or  — ).  In  the  latter  case  the  patient  can 
state  readily  that  he  hears  the  fork  louder  when  placed 
upon  the  bone  than  through  the  air.  When  the  disease 
is  localized  in  the  sound-perceiving  parts  without  lesion 
in  the  middle  ear,  the  normal  ratio  of  Rinne' s  test  is  not 
changed  (A.  C.  >  B.  C),  but  the  loudness  is  diminished 
both  ways.  In  lesions  affecting  both  the  middle  and 
internal  ear  the  test  is  often  indecisive. 

In  Weber's  test  a  tuning-fork  is  placed  in  the  median 
line  on  the  forehead  or  against  the  teeth.  It  is  then 
heard  equally  loud  in  both  ears  if  normal  or  if  symmetri- 
cally diseased.  Any  one-sided  interference  with  sound- 
conduction  intensifies  the  loudness  on  that  side,  and  in 
pronounced  instances  the  patient  locates  the  sound 
entirely  in  the  affected  ear.  This  can  be  imitated  by 
stopping  the  healthy  ear  of  one  side  with  a  plug.  If  both 
drums  are  diseased,  the  sound  is  referred  to  the  ear  most 
affected.  On  the  other  hand,  any  disease  in  the  sound- 
perceiving  apparatus  reduces  the  perception  on  the 
affected  side.  In  complicated  lesions  Weber's  test,  too, 
is  not  conclusive. 

Schwabach's  test  consists  in  measuring  the  time  of  per- 
ception in  seconds  when  the  fork  struck  with  uniform 
force  is  set  upon  the  vertex  of  the  head.  Any  pronounced 
shortening  of  the  time  the  tone  is  heard  by  bone-con- 
duction argues  in  favor  of  a  lesion  in  the  sound-perceiving 
organ. 

Gell^'s  test  is  intended  to  demonstrate  fixation  of  the 
foot-plate  of  the  stirrup  (ankylosis).  A  rubber  tube  is 
put  air-tight  into  the  meatus,  and  the  air  in  it  is  com- 
pressed by  means  of  a  bulb.  During  the  time  the  pres- 
sure acts  upon  the  drumhead  a  sounding  tuning-fork  set 
on  the  tube  is  heard  enfeebled  if  the  stapes  is  movable 
(normal),  while  the  intensity  of  the  sound  is  not  altered 
in  case  of  immobility  of  this  ossicle. 

26 


402  SUBJECTIVE   SYMPTOMS    IN    EAR    DISEASES. 

'  The  various  tuning-fork  tests  may  all  prove  more  or 
less  inconclusive  in  doubtful  cases.  When  the  results — 
positive  or  negative — are  well  pronounced  and  the  differ- 
ent tests  agree,  the  site  of  a  lesion  can  be  correctly  local- 
ized on  the  basis  of  functional  tests.  This  is  true  in  the 
majority  of  clinical  cases.  There  are,  however,  not  rare 
exceptions  in  which  the  different  tests  do  not  agree  and 
in  which  our  conclusions  drawn  from  these  tests  must  be 
guarded. 

310.  Inspection  of  the  meatus  and  drumhead  requires 
the  use  of  a  perforated  mirror,  since  otherwise  the  ex- 
aminer would  cut  off  his  own  light.  The  methods  of 
illumination  have  been  discussed  in  Chapter  III.,  1  23. 
The  view  is  hindered  by  the  tortuosity  of  the  meatus  and 
the  hairs  in  it.  The  meatus  is  straightened  by  pulling  the 
auricle  upward  and  backward.  The  hairs  are  crowded 
aside  by  a  speculum.  This  may  be  metal  or  hard  rubber. 
It  should  be  cylindric  as  far  as  it  enters  the  meatus,  while 
its  outer  end  flares  in  order  to  admit  more  light.  All 
other  shapes  are  not  so  advantageous.  The  diameter 
varies  from  3  to  7  mm.,  according  to  the  size  of  the 
meatus,  the  larger  size  permitting  the  best  view  (Fig. 
116). 

If  the  view  is  obstructed  by  the  presence  of  wax,  epi- 
dermis scales,  or  pus,  the  meatus  should  be  cleansed  by 
syringing.  The  water  must  be  warm,  as  cold  water  as 
well  as  warm  water  with  undue  force  causes  discomfort 
and  dizziness.  While  sterility  is  theoretically  desirable, 
no  harm  can  be  traced  to  ordinary  clean  water.  In  acute 
suppurative  inflammation,  however,  routine  syringing 
should  be  omitted.  A  rubber-bulb  syringe  of  ^  to  ^ 
pint  capacity  is  rather  more  convenient  than  a  piston 
syringe.  Small  syringes  are  not  advantageous.  The  noz- 
zle should  be  thin  enough  to  enter  the  meatus.  If  neces- 
sar}'  to  insert  the  nozzle  deeply, — for  instance,  when 
thick  pus  is  present, — it  is  best  to  protect  it  by  slipping 
over  its  tapering  end  a  bit  of  soft  drainage-tubing  (about 


THE   NORMAL    DRUMHEAD.  4O3 

3  mm.  thick).     This  soft  extension  of  the  nozzle  saves 
unnecessary  pain  on  contact. 

The  normal  membrana  tympani  appears  as  a  grayish, 
translucent  membrane  closing  the  meatus  (Fig.  117) 
(comp.  Fig.  I,  Plate  II.).  It  is  slightly  elliptic  rather 
than  circular  in  outline,  and  its  long  axis  deviates  up- 
ward and  forward  about  10  to  15  degrees  from  the  vertical. 
Through  the  pellucid  membrane  the  handle  of  the  ham- 
mer can  be  seen  attached  to  it  on  its  internal  side  in  the 
line  of  its  long  axis  and  reaching  from  just  below  its  center 
to  nearly  its  upper  periphery.  At  the  upper  end  of  the 
handle  the  neck  of  the  hammer  is  seen  as  an  apparently 
prominent  point.  From  the  point  two  streaks  radiate 
toward  the  periphery,  the  anterior  and  posterior  folds, 
which    separate  the   membrana  tympani  proper  or  tense 


Fig.  1 16. — Ear  speculum  :  Toynbee's  (in         Fig.  1 1 7. — Normal  membrana 
metal)  ;  Politzer's  (in  hard  rubber).  tympani  (left). 

portion  of  the  drumhead  from  its  flaccid  upper  extension, 
or  Shrapnell's  membrane.  The  latter  is  not  so  translu- 
cent as  the  tense  portion.  It  can  be  seen  well  only  in  a 
roomy  meatus.  The  handle  of  the  hammer  slants  inward 
and  downward  about  35  degrees  from  the  vertical.  Hence, 
on  the  whole,  the  drumhead  is  somewhat  funnel-shaped, 
the  sides  of  the  funnel  being,  moreover,  slightly  convex 
toward  the  examiner.  Besides  the  whole  membrane,  or, 
more  accurately  speaking,  a  plane  laid  through  its  rim, 
slants  downward  and  inward  and  forward  and  inward. 
The  inferior  and  anterior  sides  of  the  meatus  are  thus 
longer  than  the  other  sides.  On  account  of  its  shape 
the  drumhead  presents  to  the  examiner  a  bright  light 
reflection  next  to  the  lower  end  of  the  handle  of  the 
hammer,  the  triangular  spot  or  light-reflex. 


404  SUBJECTIVE   SYMPTOMS    IN    EAR    DISEASES. 

311.  Important  changes  are  noted  in  the  appearance  of 
the  drumhead  in  disease.  Serous  catarrh,  when  acute,  may 
give  rise  to  red  vascular  streaks  parallel  to  the  manubrium. 
In  acute  otitis  media  the  entire  membrane  is  uniformly 
red  on  account  of  its  vascularity.  Chronic  catarrh  changes 
the  pellucid  appearance  into  a  dull  gray  color  with  cloudi- 
ness ultimately  effacing  the  light-reflex.  In  the  course 
of  long-standing  catarrh  partial  calcification  of  the  drum- 
head may  occur  in  the  form  of  whitish  chalky  spots. 

Whenever  obstruction  of  the  Eustachian  tube  confines 
the  air  in  the  middle  ear,  it  is  partially  absorbed  and 
its  tension  sinks  below  the  pressure  exerted  by  the  atmos- 
phere upon  the  external  side  of  the  membrana  tympani. 
The  latter  is  hence  pressed  inward,  its  funnel-shaped 
indentation  is  exaggerated,  and  the  inward  slant  of  the 
manubrium  is  increased.  On  account  of  being  more 
nearly  horizontal  than  normally,  the  handle  of  the  ham- 
mer is  seen  foreshortened  under  the  circumstances.  Both 
the  bony  manubrium,  as  well  as  the  anterior  and  poste- 
rior folds  between  the  tense  and  flaccid  portion  of  the 
drumhead,  appear  strikingly  prominent,  while  the  light- 
reflex  is  somewhat  enlarged.  These  appearances  indicate 
Eustachian  obstruction  and  are  common  to  all  forms  of 
catarrh  of  the  middle  ear. 

Morbid  effusions  of  fluid  in  the  middle  ear  can  be  seen 
through  the  tympanic  membrane  if  the  latter  is  neither 
thickened  and  cloudy  nor  congested  to  an  extent  to  render 
it  opaque.  The  lower  part  of  the  drumhead  appears  yel- 
lowish or  greenish,  and  a  horizontal  black  line  shows  the 
upper  level  of  the  fluid.  If  air  be  blown  in  through  the 
Eustachian  tube,  air-bubbles  can  sometimes  be  seen  in 
the  fluid  present.  When  there  is  much  effusion,  the 
drumhead  bulges  and  the  light-reflex  is  effaced.  More 
often,  however,  the  membrane  is  drawn  inward  by  reason 
of  the  diminished  intratympanic  pressure,  even  when 
there  is  moderate  effusion. 

In  acute  purulent  otitis  media  a  protruding  pouch  is 
in   rare   instances   seen    in  the  upper  rear   part   of  the 


THE    MEMBRANA    TYMPANI    IN    EAR    DISEASES.  4O5 

drumhead,  formed  by  a  hernia  of  the  mucous  layer 
through  the  deficient  or  atrophic  middle  lamina.  Inter- 
stitial abscesses  have  been  seen  in  the  membrana  tym- 
pani.  Serous  blisters  occur  on  its  external  surface  in 
myringitis.  In  this  inflammation,  localized  in  the  drum- 
head, but  also  in  influenza  otitis,  minute  hemorrhages 
are  found  in  its  substance.  They  may  also  be  produced 
by  traumatism.  In  chronic  myringitis  the  membrane  is 
sometimes  studded  with  small  papillary  growths. 

Traumatic  ruptures  of  the  drumhead  from  foreign 
bodies  or  concussions  are  mostly  linear,  with  edges  suf- 
fused by  blood.  The  tympanic  membrane  is  normally 
air-tight,  and  any  perforation  in  it  is  indicative  of  injury 
or  present  or  former  disease. 

312.  Perforations — the  result  of  suppuration  of  the 
middle  ear — may  be  of  pin-point  size  in  a  mild  acute 
case,  or  may  include  the  entire  drumhead  in  a  more  de- 
structive type  of  disease.  A  very  small  hole  is  sometimes 
difficult  to  see  if  covered  by  loose  epidermis  scales  or 
dried  secretion,  or  if  hidden  by  the  prominence  of  the 
wall  of  the  meatus.  In  shape  perforations  may  be  round, 
oval,  or  bean-shaped.  They  may  occur  in  any  part  of 
the  membrane.  It  is  important  to  note  whether  they  are 
in  the  tense  or  flaccid  portions  of  the  drumhead.  Small 
perforations  in  Shrapnell's  membrane  lead  into  the  attic 
and  do  not  always  communicate  with  the  tympanic  cavity. 
Not  rarely  perforations  of  Shrapnell's  membrane  are  com- 
plicated by  defects  at  the  upper  periphery  of  the  bony 
rim,  and  a  fissure  may  thus  be  found  leading  into  the 
attic.  Where  a  large  area  of  the  drumhead  has  been  de- 
stroyed, a  part  or  even  the  whole  of  the  hammer  and 
anvil  may  be  also  lost. 

When  a  suppurative  otitis  has  passed  its  acute  stage, 
regenerative  changes  begin  at  the  edge  of  the  perforation. 
Provided  the  defect  is  not  very  large,  it  usually  closes  as 
soon  as  all  secretion  has  ceased.  But  if  the  secretion 
continues  after  the  acute  stage, — in  other  words,  in  all 
protracted  inflammations, — the  edge' of  the  defect  becomes 


406  SUBJECTIVE    SYMPTOMS    IN    EAR    DISEASES. 

covered  with  epithelium  and  the  perforation  cannot  close 
and  remains  permanently  open.  On  the  other  hand,  all 
holes  made  by  the  surgeon  close  with  remarkable  pre- 
cision. Even  when  the  entire  drumhead  has  been  excised 
a  regeneration  usually  follows. 

Through  the  hole  in  the  drumhead — if  not  too  small — 
the  mucous  membrane  of  the  tympanic  cavity  is  seen, 
pale  when  healthy,  more  or  less  reddened  and  thickened 
when  inflamed. 

In  case  of  doubt  about  the  existence  of  a  perforation  a 
communication  with  the  drum  cavity  can  be  shown  in 
various  ways.  On  inspection  through  a  Siegle  speculum 
(see  below)  the  drumhead  will  not  be  seen  to  move  to  and 
fro  with  changing  air-pressure.  Auscultation  gives  a 
perforation  noise  when  air  is  forced  through  the  Eusta- 
chian tube.  If  the  ear  be  filled  with  water,  air  forced 
through  the  tube  bubbles  out  of  the  meatus.  These  tests 
fail  if  the  hole  (in  Shrapnell's  membrane)  leads  only  into 
the  attic  and  not  into  the  drum  cavity  proper. 

Healed  perforations — if  larger  than  a  pin-point — are 
closed  by  a  cicatricial  membrane  more  translucent  and 
more  yielding  than  the  membrana  tympani  on  account  of 
the  absence  of  the  tense  middle  layer.  lyarge  cicatrices 
are  often  flaccid  and  of  abnormal  mobility. 

313.  Of  limited  utility  is  the  examination  of  the  drum- 
head through  the  Siegle  or  pneumatic  speculum  (Fig. 
118).  It  is  a  speculum  fitting  air-tight  into  the  meatus  by 
means  of  a  soft-rubber  tube  slipped  over  it  with  its  external 
end  closed  by  a  magnifying  lens.  Through  a  lateral  tube 
the  air  can  be  exhausted  or  compressed.  The  extent  of 
movement  of  the  handle  of  the  hammer  under  varying 
air-pressure  indicates  the  mobility,  or,  vice  versd,  the 
rigidity,  of  the  malleo-incudal  articulation.  The  pneu- 
matic speculum  may  be  used  for  massage  of  the  drum- 
head. Alternate  rarefaction  and  compression  of  air  at 
the  rate  of  two  or  three  times  a  second  can  be  practised 
with  the  mouth  or  by  means  of  a  small  rubber  bulb 
(without   valve).     Elaborate    miniature   pumps   run   by 


PATENCY  OF  THE  EUSTACHIAN  TUBE.        407 

compressed  air  or  electricity  have  been  devised  for  the 
same  purpose  and  make  an  impressive  piece  of  office 
furniture,  but  accomplish  not  much  more  than  simpler 
apparatus.  While  vibrating  massage  of  the  drumhead  is 
of  some  slight  but  unquestionable  efficacy  in  the  treat- 
ment of  chronic  middle-ear  disease,  its  utility  has  been 
much  exaggerated.  As  it  requires  a  long  continuance,  it  is 
simplest  to  teach  the  patient  to  do  it  himself  twice  daily 
for  one  to  two  minutes,  by  means  of  a  rubber  tube  led 
from  his  mouth  to  his  ear.  Practically  the  same  influence 
can  be  obtained  by  inserting  the  forefinger  into  the  meatus, 
grasping  the  lobule  with  the  thumb,  and  making  rhythmic 


Fig.  118. — Siegle's  pneumatic  ear  speculum. 


movements  to  and  fro.     The  finger  acts  upon  the  air  in 
the  meatus  like  the  piston  of  a  syringe. 

314.  In  all  diseases  of  the  middle  ear  it  is  important  to 
determine  the  degree  of  patency  of  the  Eustachian  tube. 
There  is  no  convenient  method  of  ascertaining  the  degree 
of  patency  in  absolute  measure — for  instance,  with  refer- 
ence to  the  air-pressure  necessary  for  inflation.  But  in- 
formation sufficiently  accurate  for  clinical  purposes  can 
be  easily  obtained.  Normally  an  expiratory  effort  made 
while  mouth  and  nostrils  are  held  closed  will  at  once 
force  open  the  tubes,  and  the  subject  feels  the  ear  filling 
with  air  under  pressure  (Valsalva's  experiment).  The 
full  feeling  is  instantly  relieved  by  swallowing,  which 
act,  by  causing  gaping  of  the  Eustachian  lips,  permits 
equalization  of  air-pressure  in  the  drum  cavity  and  the 
throat.  The  more  obstructed  the  Eustachian  channels 
by  either  swelling  or  sclerosis  of  the  mucous  membrane, 


408  SUBJECTIVE    SYMPTOMS    IN    EAR    DISEASES. 

the  more  difficult  is  Valsalva's  experiment.  The  patient 
can  thus  indicate  very  accurately  any  difference  between 
the  two  sides.  When  the  Eustachian  obstruction  is  con- 
siderable, inflation  by  the  Valsalva  method  becomes  im- 
possible. Politzer  inflates  the  middle  ear  by  vigorous 
compression  of  a  large  rubber  bag  while  swallowing  water 
held  in  the  mouth.  The  bag  should  have  at  least  300  c.c. 
(10  oz.)  capacity  (Fig.  119).  Its  nozzle  should  have 
a  wide  caliber,  and  should  be  connected  by  means  of  a 
short,  soft-rubber  tube  with  a  large  glass  ball  fitting  air- 
tight into  the  nostril.  During  swallowing  the  palate 
closes  the  pharynx,  and  the  air,  forced  into  the  nostril 
and  thus  confined,  forces  its  way  through  the  Eustachian 
tube  while  the  latter  gapes.  The  greater  the  Eustachian 
obstruction,  the  more  pressure  is  required  to  force  in  the 


Fig.  119. — Politzer  air-bag. 

air,  until,  in  extreme  instances,  the  Politzer  inflation 
becomes  impossible.  By  bending  the  head  forcibly 
toward  one  shoulder  the  gaping  of  the  Eustachian  orifice 
is  interfered  with  on  the  flexed  side,  and  the  procedure 
can  thus  be  partially  limited  to  one  ear.  If  the  com- 
pression of  the  bag  does  not  coincide  with  swallowing, 
the  air  gets  into  the  esophagus  and  produces  discomfort. 
In  very  rare  instances  the  Politzer  inflation  has  caused 
the  rupture  of  cicatrices  (of  perforations)  in  the  drum- 
head, but  without  doing  any  permanent  harm.  Gruber 
has  substituted  the  forcible  intonation  of  a  harsh  guttural 
"  k  "  or  the  syllable  "  hock  "  for  the  act  of  swallowing. 
The  palate  is  closed,  but  the  Eustachian  mouth  does 
not  gape  during  the  articulation  of  "hock,"  and  hence 
Gruber  may  fail,  where  Politzer  succeeds. 


EUSTACHIAN   CATHETERIZATION.  409 

315.  For  most  diagnostic  and  therapeutic  purposes  in- 
flation by  means  of  the  Eustachian  catheter  is  the  most 
satisfactory  procedure  (Fig.  120).  With  the  catheter  well 
introduced  into  the  Eustachian  orifice  air  can  be  forced 
easily  through  a  passage  so  swollen  that  inflation  by 
other  methods  is  impossible.  Besides,  we  can  gauge  its 
result  objectively  by  listening  through  a  tube  connecting 
the  ear  of  the  patient  with  that  of  the  surgeon  (Fig.  121). 
The  introduction  of  the  catheter  should  not  be  painful, 
although  always  disagreeable.  When  the  nasal  passage 
is  inflamed,  sensitive,  or  narrowed,  a  cocain  spray  may 
be  used,  especially  in  timid  children.  Metal  catheters 
are  preferable  to  rubber,  as  they  keep  their  shape  on 
boiling.     Since  syphilis  has   been  transmitted   through 


*^ 


Fig.  120. — Eustachian  catheter. 


Fig.  121. — Auscultation  tube. 

the  use  of  the  catheter,  thorough  cleanliness,  if  not  abso- 
lute disinfection  by  boiling  soda  solution,  is  imperative. 
Flexibility  of  the  instrument  is  no  object,  since  when  it 
has  a  proper  curve  we  can  very  rarely  improve  the  latter 
by  bending  it.  Its  end  should  be  rounded,  and  the 
catheter  must  not  be  needlessly  long — not  more  than  15 
cm.  Many  in  the  shops  are  of  improper  length.  The 
instrument  is  introduced  by  gliding  it  along  the  floor  of 
the  nose  until  its  tip  touches  the  pharyngeal  wall,  where- 
upon it  is  turned  toward  the  ear  so  that  its  curve  lies  in  a 
plane  about  horizontal  or  slightly  tilted  upward  and  out- 
ward. It  is  then  withdrawn  1.5  to  2  cm.  (in  the  adult), 
and,  as  a  rule,  it  can  now  be  felt  that  the  tip  glides  over 
the  prominence  of  the  Eustachian  lip  into  its  orifice. 


4IO  SUBJECTIVE   SYMPTOMS    IN    EAR    DISEASES. 

Upon  blowing  through  the  tube  the  air  is  heard  entering 
the  middle  ear.  If  stenosis  of  the  nasal  passage  prevents 
the  regular  mode  of  seeking  the  Eustachian  mouth,  the 
catheter  must  be  manipulated  by  gentle  rotation  in  dif- 
ferent directions.  A  very  thin,  flexible,  hard-rubber 
tube  has  the  advantage  over  a  stifif  catheter  in  this  case. 
If  the  obstacle  in  the  nose  cannot  be  overcome,  the 
catheter  should  be  inserted  through  the  nostril  of  the 
other  side  and  turned  toward  the  desired  ear  after  its 
beak  has  passed  the  nasal  septum.  By  forcing  the  outer 
end  of  the  catheter  away  from  the  septum  it  is  generally 
possible  to  inflate  the  opposite  ear.  Inflation  is  done 
with  a  single  (not  double)  rubber  hand-bulb  (with  air- 
valve),  connected  by  means  of  soft-rubber  tubing  with  a 
tip  to  fit  into  the  end  of  the  catheter.  The  listener  hears 
a  faint,  clear,  blowing  sound  when  the  air  enters  a  nor- 
mal Bustachian  tube.  Constriction  or  swelling  of  the 
tube  gives  the  sound  a  hissing  quality.  Mucus  in  the 
tube  or  fluid  in  the  middle  ear  produces  a  bubbling  rale. 

Of  great  prognostic  significance  is  the  degree  of  sub- 
jective improvement  in  hearing  or  the  lessening  of  tin- 
nitus and  fulness  obtained  by  inflation  with  any  method. 

The  only  possible  accident  from  the  use  of  the  catheter 
is  emphysema  of  the  pharynx  and  side  of  the  neck.  If 
the  tip,  especially  if  rough,  happens  to  scratch  the  mucous 
membrane,  the  air  may  enter  the  wound  and  distend  the 
interstitial  lymph-spaces.  An  immediate  tumefaction 
occurs,  with  feeling  of  oppression.  The  swelling  is  soft, 
elastic,  and  can  be  deeply  indented  by  the  finger.  It  dis- 
appears in  a  few  hours  without  harm. 

In  order  to  blow  the  vapor  of  chloroform  into  the  mid- 
dle ear,  the  rubber  tip  of  the  air-bag  fitting  into  the 
catheter  can  be  dipped  into  this  fluid,  or  a  drop  of  it  may 
be  dropped  into  a  Politzer  bag.  The  vapor  of  iodin  or 
of  turpentine  can  be  used  for  Eustachian  inflation  by 
placing  the  material  (tincture  of  iodin  or  turpentine)  on 
cotton  in  a  capsule  between  the  rubber  bag  and  the  noz- 
zle.    A  similar  metallic  capsule  can  be  used  to  heat  the 


INFLATION    IN    EAR    DISEASES.  4II 

air  by  holding  it  over  a  flame.  Finely  divided  chlorid 
of  ammonium  may  be  generated  for  inflation  by  letting 
the  air  pass  through  a  branched  tube  over  NH3  and  HCl 
solution  contained  in  separate  bottles.  As  the  separate 
currents  of  air  laden  with  the  fumes  join  in  a  third  recep- 
tacle, the  NH4CI  is  formed  as  a  finely  suspended  cloud 
(Fig.    122). 

Probing  of  the  Eustachian  tube  can  be  practised  with 
a  flexible  celluloid  or  rubber  probe  or  a  stifi"  catgut  (violin 


Fig.  122. — Apparatus  for  developing  chlorid  of  ammonium  in  a  state  of 
fine  subdivision.  A  current  of  air  is  blown  in  the  direction  of  the  arrow  through 
the  two  bottles  on  the  right,  one  containing  hydrochloric  acid,  the  other  a  solu- 
tion of  ammonia.  When  the  two  vapors  meet  in  the  bottle  on  the  left,  which 
contains  water,  chlorid  of  ammonium  is  formed,  while  any  excess  of  either  acid 
or  ammonia  fumes  is  absorbed  by  the  water.  The  tube  on  the  left  side  connects 
with  the  catheter. 

D-string)  introduced  through  the  catheter.  Normally  a 
probe  suitably  marked  to  indicate  its  length  within  the 
catheter  can  be  pushed  about  25  mm.  into  the  tube 
without  meeting  with  an  obstacle.  It  is,  however,  diffi- 
cult and  painful  to  carry  the  probe  beyond  the  isthmus 
of  the  tube.  A  uniform  swelling,  as  well  as  a  circum- 
scribed constriction,  can  be  recognized  by  opposing  the 
introduction.  The  utility  of  the  probe  for  either  diag- 
nostic or  therapeutic  purposes  is  not  generally  admitted. 


412  SUBJECTIVE    SYMPTOMS    IN    EAR    DISEASES. 

The  diagnosis  of  middle-ear  disease  is  completed  by 
full  examination  of  nose  and  pharynx. 

All  ear  instruments  should  be  scrupulously  cleaned 
after  use,  and  all  those  coming  into  contact  with  dis- 
eased surfaces  should  be  sterilized.  For  this  purpose 
nothing  is  so  satisfactory  as  boiling  soda  solution  (see 
1[  30,  Chap.   III.). 

316.  Parace7itesis  (operative  perforation)  of  the  drum- 
head is  often  done  for  therapeutic,  rarely  for  diagnostic 
purposes.  The  meatus  is  syringed  to  remove  wax  and 
scales  and  sterilized  by  a  bath  of  at  least  three  minutes' 
duration  with  a  reliable  disinfectant  (3  per  cent,  solution 
of  carbolic  acid  or  carbolic  acid  in  glycerin  12  per  cent.). 
A  needle  or  knife  mounted  on  a  shank  at  an  angle  of  140 


^ 


Fig.  123. — Paracentesis  needle  and  knife  for  operation  on  drumhead,  with 
universal  handle  for  ear  instruments ;  also  two  forms  of  curets  for  middle-ear 
surgery. 

degrees(Fig.  123)  is  thrust  through  the  drumhead,  making 
a  long  vertical  slit,  of  course  under  good  illumination  and 
through  a  wide  speculum.  The  incision  is  preferably 
made  where  the  membrane  bulges  most.  Paracentesis 
causes  a  momentary  sharp  pain,  especially  when  the 
drumhead  is  inflamed.  It  is  not  possible  to  produce 
local  anesthesia  by  means  of  a  watery  solution  of  cocain, 
since  this  is  not  absorbed  through  the  skin.  Cocain  dis- 
solved in  anilin  oil  (Gray)  has  likewise  proved  inefficient. 
A  solution  consisting  of  equal  parts  of  cocain,  menthol, 
and  carbolic  acid  (Bonain)  gives  a  partial  and  not  always 
reliable  anesthesia.  As  this  mixture  is  slightly  caustic, 
it  should  be  applied  cautiously  on  a  minute  pledget  of 
cotton  on  a  probe  to  the  area  to  be  incised. 

A  paracentesis  properly  done,  and  with  aseptic  pre- 


EAR-TRUMPETS. 


413 


cautions,  is  practically  free  from  danger.  There  are  on 
record  a  few  instances  in  which  the  bulb  of  the  jugular 
vein  protruding  through  a  defective  floor  into  the  tym- 
panic cavity  was  wounded.     The  alarming  hemorrhage 


Fig.  124. — Conversation  tube. 

was  controlled  by  a  tampon  in  most  instances.  It  is 
hence  best  not  to  cut  down  to  the  inferior  rim  of  the 
drumhead.  After  paracentesis  the  syringe  should  not  be 
used. 

317.  Defective  hearing  can  be  assisted  by  intensifica- 
tion of  sounds  by  means  of 
speaking-tubes  or  ear-trump- 
ets (Figs.  124  and  125). 
Their  underlying  principle  is 
the  concentration  of  sound- 
waves in  a  funnel-shaped  re- 
ceiver. A  simple  hollow 
hard-rubber  cone  with  soft- 
rubber  tube  leading  into  the 
ear  is  usually  the  most  satis- 
factory pattern  for  listening 
to  individual  conversation. 
It  is  not  possible  to  advise  a 
patient  which  model  he  should 
select  for  general  purposes. 
It  is  better  to  let  him  choose  by  actual  trial  of  different 
patterns.  As  a  rule,  the  larger,  and  hence  the  more 
undesirable,  the  trumpet,  the  more  it  collects  the  sound. 
Some  patterns  modify  the  timber  unpleasantly.      Small 


Fig.  125. — London  hearing  horn. 


414  SUBJECTIVE    SYMPTOMS    IN    EAR    DISEASES. 

contrivances  are  generally  useless.  The  audiphone  of 
Rhodes,  a  slightly  curved  fan  of  hard  rubber  held 
against  the  teeth  as  a  resounding  board,  is  a  very  con- 
venient instrument,  but  is  generally  not  found  quite  so 
useful  as  a  trumpet. 

All  patients  with  progressive  impairment  of  hearing 
should  be  advised  to  learn  to  "read"  speech  by  watch- 
ing the  lips  of  the  speaker.  By  proper  and  long-con- 
tinued attention,  begun  while  they  can  still  hear  fairly 
well,  they  will  ultimately  be  able  to  compensate  in  part 
their  deficient  hearing  by  interpretation  of  the  lip-move- 
ments. 


CHAPTER  XXXIII. 

DISEASES   OF   THE   EXTERNAL  EAR. 

OTHEMATOMA.  —  PERICHONDRITIS.  —  ECZEMA.  —  DIFFUSE 
OTITIS  EXTERNA.— FURUNCLES PARASITIC  INFLAM- 
MATION OF  THE  MEATUS.— WAX  AND  EPIDERMIS 
PLUGS. 

318.  Othematoma  is  a  localized  swelling  in  the  auricle 
due  to  extravasation  of  blood  under  the  perichondrium. 
It  forms  a  soft  tumor  of  variable  size,  with  some  discolora- 
tion of  the  skin,  usually  in  the  upper  part  of  the  auricle, 
never  in  the  lobule.  It  causes  but  little  annoyance,  but 
is  sometimes  tender  to  touch.  It  is,  as  a  rule,  due  to 
blows  upon  the  ear,  hence  seen  mostly  in  pugilists.  It 
was  evidently  more  common  among  the  fighters  of  classic 
antiquity,  whose  writers  mention  it  and  some  of  whose 
statues  show  the  deformity  which  othematoma  sometimes 
leaves.  It  is  of  remarkable  frequency  (about  i  per  cent) 
among  the  insane,  in  whom  probably  preceding  degenera- 
tion of  the  cartilage  predisposes  to  effusions  of  blood, 
perhaps  even  without  trauma. 

The  effusion  is  underneath  the  perichondrium.  It 
usually  clots  and  sometimes  becomes  encysted.  The 
smaller  accumulations  of  blood  are  apt  to  disappear  spon- 
taneously in  the  course  of  many  weeks.  They  may, 
however,  leave  some  shrinkage  and  deformity  of  the 
cartilage,  especially  after  recurrent  attacks.  The  ab- 
sorption can  be  favored  by  daily  massage.  When  no 
favorable  change  is  seen  after  the  lapse  of  three  or  four 
weeks,  an  incision  may  be  made  into  the  cyst.  But  since 
reaccumulation  is  apt  to  take  place,  the  cavity  should  be 
cleansed  as  far  as  is  necessary  with  a  sharp  scoop  and  the 
wound  packed  with  iodoform  gauze. 

415 


4l6  DISEASES    OF    THE    EXTERNAL    EAR. 

319.  Perichondritis  of  the  auricle  is  very  rare.  It 
shows  its  inflammatory  nature  by  diffuse  doughy  swelling, 
redness,  tenderness,  sometimes  with  considerable  pain. 
The  course  is  very  tedious  and  lasts  many  weeks.  The 
inflammation  may  disappear,  or  it  may  lead  to  abscess 
and  phlegmonous  sloughing.  Its  cause  is  usually  not 
known,  but  it  has  been  ascribed  to  syphilis  in  some 
instances.  As  long  as  there  is  no  suppuration  tincture 
of  iodin  and  ichthyol  may  be  applied  locally.  As  soon 
as  pus  is  suspected,  it  must  be  treated  surgically. 

320.  Hczema  is  a  frequent  skin  affection  and  the 
only  common  one  involving  the  auricle  and  meatus. 
It  begins  in  the  form  of  minute  vesicles,  which  spread  at 
first  rapidly  and  soon  change  into  moist  scabs  covering 
an  excoriated  surface.  It  is  usually  seen  in  its  chronic 
form  and  may  persist  indefinitely.  The  subjective  annoy- 
ances are  burning  and  itching.  When  seen  in  children, 
it  raises  the  suspicion  of  scrofula,  but  it  does  occur  as 
well  in  apparently  perfect  health,  both  in  children  and  in 
adults.  In  the  writer's  experience  the  only  prompt  treat- 
ment has  been  the  free  use  of  nitrate  of  silver  in  strong 
solution — 30  per  cent,  or  the  solid  stick — to  the  excori- 
ated surface  after  complete  detachment  of  all  crusts. 
The  pain  can  be  relieved  by  the  previous  application  of 
cocain.  The  abraded  surface  becomes  covered  with  a 
thin  eschar,  which  blackens  when  exposed  to  light,  and 
underneath  this  film  regeneration  of  the  epithelium  takes 
place.  Sometimes  one  application  suffices  to  check 
the  secretion,  but  mostly  a  few  repetitions  are  needed. 
Wherever  moisture  is  seen,  the  eschar  should  be  de- 
tached daily  and  the  surface  brushed  again  until  per- 
manently dry.  The  persisting  dry  dermatitis  and  the 
liability  to  immediate  relapses  are  effectually  checked  by 
the  use  of  a  salve  of  oil  of  cade  (i  in  4  of  lanolin  stiffened 
by  oxid  of  zinc).  If  objections  are  raised  to  the  pain  and 
blackening  produced  by  the  nitrate  of  silver,  Peruvian 
balsam  may  be  applied  instead,  but  with  less  prompt 
effect.      The  various  dusting-powders   used  for  eczema 


DIFFUSE    INFLAMMATION    OF    THE    EXTERNAL    MEATUS.    417 

in  other  localities  do  not  prove  very  serviceable  on  the 
auricle. 

Eczema  in  the  squamous  form  is  sometimes  limited  to 
the  interior  of  the  meatus,  producing  distressing  itching. 
With  good  illumination  the  skin  is  seen  scaly,  like  dan- 
druff on  the  scalp.  There  may  be  a  trifling  serous  exuda- 
tion which  is  apt  to  be  fetid.  Without  careful  inspection 
this  skin  disease  is  easily  overlooked.  In  this  form  it 
yields  very  promptly  to  a  salve  containing  3  to  5  per  cent, 
each  of  resorcin  and  precipitated  sulphur.  The  relief  of 
the  intolerable  itching  is  generally  very  gratefully  ac- 
knowledged. 

Itching  in  the  meatus — the  pruritus  of  some  writers — 
may,  however,  be  due  to  other  conditions  as  well  as 
eczema.  It  is  sometimes  dependent  on  vascular  turges- 
cence  of  the  pharyngeal  end  of  the  Eustachian  tube,  and 
in  such  cases  is  more  or  less  relieved  by  Eustachian  in- 
flation. Severe  itching  not  due  to  eczema  of  the  meatus 
indicates,  as  a  rule,  a  neurotic  disposition  and  may  prove 
a  serious  puzzle  to  the  therapeutist. 

321.  DiflPuse  inflammation  of  the  external  meatus 
(diflPuse  otitis  externa)  is  recognizable  by  more  or  less 
swelling  of  the  walls  of  the  meatus,  even  to  the  point 
of  complete  occlusion,  with  variable  and,  indeed,  some- 
times very  severe  pain.  There  may  be  slight  serous  or 
seropurulent  discharge,  or  none  at  all.  The  disease  is 
not  always  the  same  etiologically.  It  is,  of  course,  an 
inflammation  of  the  skin,  generally  also  of  the  deeper 
tissues  of  the  meatus,  due  to  the  invasion  by  pyogenic 
microbes.  In  some  cases  it  is  the  consequence  of  eczema; 
in  others  it  results  from  scratching  of  the  delicate  skin  of 
the  meatus.  Patients  cannot  be  warned  too  emphatically 
against  using  hairpins  and  similar  implements  to  relieve 
itching.  Sometimes  the  apparently  diffuse  inflammation  is 
really  due  to  multiple  but  small  furuncles.  Again,  it  may 
result  from  irritating  chemicals  injudiciously  dropped  into 
the  meatus.  Sometimes  a  desquamative  inflammation  of 
the  skin,  with  retention  and  secondary  decomposition  of 

27 


41 8  DISEASES    OF   THE   EXTERNAL    EAR. 

moist  scales,  starts  the  process,  but  in  all  instances  care 
must  be  taken  to  determine  the  presence  or  absence  of 
inflammation  of  the  middle  ear  when  the  meatus  is  found 
swollen.  When  the  swelling  does  not  permit  a  view  of 
the  drumhead,  this  diagnostic  question  may  have  to  be 
left  in  suspense. 

The  walls  of  the  meatus  are  seen  swollen,  sometimes  in 
actual  contact,  but  are  very  little  reddened.  The  greater 
the  swelling,  the  more  severe  the  pain  and  the  more  the 
patient  complains  of  a  fulness  in  the  ear,  with  transient 
deafness.  With  cotton  wound  on  a  tooth -pick  search  is 
made  for  secretion.  When  the  latter  is  purulent  and 
thick,  there  is  reason  to  suspect  involvement  of  the  mid- 
dle ear.  A  thin  but  fetid  discharge  may  come  from  the 
meatus  itself  Minute  coherent  plugs  of  thick  pus  indi- 
cate furuncles. 

In  non-suppurative  instances  the  writer  has  found  no 
application  equal  to  carbolated  glycerin  (lo  per  cent.) 
dropped  into  the  meatus  with  a  drop-tube  and  retained  by 
a  plug  of  cotton.  The  inflammation,  which  might  other- 
wise last  weeks,  may  thus  yield  in  a  few  days.  When 
the  excoriated  surface  secretes  fluid  it  should  be  syringed 
with  sterile  water  through  a  fine  cannula.  If  scales  of 
skin  cannot  be  dislodged  by  the  current,  they  should  be 
scooped  out.  After  filling  the  meatus  with  carbolated 
glycerin  a  gauze  drain  should  be  introduced  beyond  the 
swelling  to  permit  drainage.  The  aseptic  drainage  is 
■especially  important  when  suppurative  inflammation  of 
the  middle  ear  is  suspected.  When  the  walls  of  the 
meatus  secrete  fluid  the  disease  is  likely  to  last  at  least  a 
week  under  treatment. 

322.  Furuncles  in  the  meatus,  or  circumscribed 
otitis  externa,  consist  of  minute  cutaneous  abscesses 
with  a  central  slough.  The  affection  is  very  painful. 
The  furuncles  are  more  often  single  than  multiple.  When 
healed,  they  are  apt  to  recur  unless  guarded  against. 
Sometimes  a  recurrence  takes  place  after  many  weeks' 
interval.      As   a   rule,    no   constitutional    cause   can   be 


FURUNCLES    IN    THE    MEATUS.  419 

learned.  They  may  be  due,  however,  to  local  traumatism 
by  scratching.  As  the  meatus  contains  atmospheric  dust 
and  probably  always  living  germs,  lesions  of  its  delicate 
skin  are  apt  to  cause  infection,  especially  by  staphy- 
lococci. 

The  furuncle  can  be  seen  as  a  small,  not  well-defined 
swelling,  exquisitely  tender  to  touch,  in  the  cartilaginous 
meatus.  After  a  day  or  two  it  shows  a  small  "head," 
which  then  breaks  with  some  relief.  The  ear  itself  feels 
stuffy.  The  great  pain  which  sometimes  radiates  over 
the  entire  side  of  the  head  may  raise  the  (unfounded)  sus- 
picion of  mastoid  disease.  Such  a  wrong  diagnosis  is 
in  rare  instances  suggested  by  a  puffy  swelling  behind  the 
ear,  due  to  a  small  abscess  started  by  the  furuncle.  The 
correct  diagnosis  should  be  guided  in  these  deceptive 
cases  by  the  brief  duration  and  the  negative  history  (no 
previous  middle-ear  disease).  Such  a  furuncular  abscess 
may  produce  a  febrile  rise  of  several  degrees. 

As  soon  as  the  purulent  contents  can  be  recognized,  the 
furuncle  should  be  incised  deeply  with  a  sharp  small 
bistoury.  The  incision  is  very  painful,  and  no  local 
application  can  prevent  the  pain.  If  the  cut  is  made 
before  the  contents  are  soft,  the  throbbing  pain  of  the 
furuncle  is  not  relieved  at  once,  although  its  course  is 
shortened.  Some  relief  can  be  obtained  subsequently  by 
filling  the  meatus  with  carbolated  glycerin.  It  should 
then  be  packed  lightly  with  a  sterile  gauze  drain.  It 
has  been  claimed  that  firm  packing  of  the  meatus  with  a 
thick  tampon  will,  after  a  while,  relieve  the  suffering 
during  the  early  stage,  but  the  writer  cannot  corroborate 
this.  Recurrence  of  furuncles  can  be  surely  guarded 
against  by  filling  the  meatus  once  in  a  day  or  two  with 
carbolic  acid  solution — either  3  per  cent,  watery  or  10 
per  cent,  glycerin  solution.  This  should  be  kept  up  for 
several  weeks. 

323.  Parasitic  otitis  externa  or  mycosis  of  the 
meatus  is  a  rather  rare  occurrence,  which  is  seldom  ob- 
served in  this  countrj'.     It  is  due  to  the  invasion  of  the 


420  DISEASES    OF    THE    EXTERNAL    EAR. 

meatus  by  a  mould  fungus,  usually  a  variety  of  aspergillus. 
It  may  cause  no  symptoms  at  all  or  more  or  less  fulness  and 
discomfort.  The  skin  scales  in  flakes,  sometimes  forming 
casts  on  which  greenish  or  black  spots  occur.  These  are 
recognized  as  a  fungus  upon  microscopic  examination. 
The  disease  is  checked  by  a  few  instillations  of  alcohol 
containing  2  per  cent,  of  salicylic  acid. 

324.  Impacted  Cerumen.— Ear  wax,  a  yellowish, 
thick,  oily  substance,  is  secreted  by  the  glands  in  the 
skin  of  the  cartilaginous  meatus  and  of  a  narrow  zone 
along  the  upper  wall  of  the  bony  part  of  the  canal.  Nor- 
mally it  dries  in  the  form  of  soft  but  crumbling  scales, 
which  are  gradually  carried  outward  by  the  normal  out- 
ward growth  of  the  epithelium.  The  process  can  be 
shown  by  making  a  stain  in  the  depth  of  the  meatus  with 
an  anilin  dye  or  nitrate  of  silver.  It  can  then  be  seen  travel- 
ing outward  slowly  in  the  course  of  weeks.  The  expul- 
sion of  the  wax  is  also  favored  by  the  movement  of  the 
joint  of  the  inferior  maxilla  communicated  to  the  car- 
tilaginous meatus.  Under  unknown  circumstances  the 
escape  of  wax  is  hindered  and  perhaps  its  rate  of  secre- 
tion increased.  A  necessary  condition  seems  to  be  naso- 
pharyngeal disease,  either  in  the  form  of  acute  attacks  or 
persistent  chronic  lesions.  The  wax  accumulates  without 
causing  any  annoyance  as  long  as  a  narrow  channel  is  still 
left.  When  this  is  filled  up  by  further  secretion  or  by 
swelling  of  the  plug  from  water,  the  patient  complains  of 
fulness,  impaired  hearing,  noises,  and  sometimes  dizzi- 
ness. Inspection  shows  the  meatus  filled  with  a  formless 
mass  of  a  color  varying  from  light  brown  to  black.  The 
condition  persists  indefinitely,  although  sometimes  the 
plug  dries  and  falls  out  after  a  long  period  of  time.  A 
long  persistence  of  impacted  wax  damages  the  ear  per- 
maijently,  though  but  to  a  slight  extent.  It  probably 
leads  to  slight  hypertrophic  changes  in  the  drum  cavity. 
Wax  plugs  occur  much  oftener  in  both  ears  than  in  one 
alone.  They  are  almost  sure  to  recur  in  the  course  of 
months  or  years,  but  the  presence  of  excessive  wax  seems 


EPIDERMIS    PLUGS.  421 

to  be  an  assurance  against  the  occurrence  of  any  form  of 
progressive  deafness.  On  the  other  hand,  absence  of  wax 
indicates  always  serious  nutritive  disturbances  in  the  mid- 
dle ear. 

Wax  plugs  should  not  be  removed  with  instruments, 
since  traumatism,  even  with  sterile  instruments,  may 
cause  infection.  Syringing  is  always  sufficient.  A  large 
syringe,  either  a  rubber  bulb  or  a  piston  syringe,  with 
thin  but  blunt  nozzle,  and  sufficient  patience  are  required. 
Coolness  of  the  water  or  too  much  force  may  cause  pain, 
dizziness,  or  even  fainting.  When  the  plug  is  difficult  to 
dislodge,  it  can  be  softened  by  a  strong  solution  of  bicar- 
bonate of  -sodium.  Either  a  few  repeated  instillations 
each  with  an  action  of  some  five  minutes  may  be  em- 
ployed, or  the  fluid  may  be  left  in  the  ear  for  hours  after 
plugging  with  cotton.  By  the  aid  of  its  solvent  action 
the  wax  plug  can  always  be  removed  without  injury. 
Any  persisting  feeling  of  fiilness  after  removal  is  relieved 
at  once  by  Eustachian  inflation. 

325.  Bpidermis  plugs  must  be  distinguished  from 
wax  plugs,  both  on  account  of  their  significance  and  the 
difficulty  of  their  removal.  They  occur  as  often  one- 
sided as  double-sided.  They  consist  of  scales  of  de- 
tached epidermis  and  are  distinctly  laminated.  They  are 
often  covered  or  interspersed  with  wax.  The  exfoliation 
is  the  result  of  a  desquamative  inflammation  of  the  skin, 
which,  by  itself,  may  cause  no  unpleasant  sensations. 
The  presence  of  epidermis  plugs  may  lead  to  infection  of 
the  walls  of  the  meatus  or  middle-ear  disease,  and  even 
to  carious  destruction  of  the  bony  walls  of  the  meatus. 
Quite  often  the  macerated  scales  contain  germs  causing 
decomposition  and  fetid  odor.  When  epidermis  scales 
are  found  in  the  external  meatus,  middle-ear  disease 
should  be  thought  of  as  a  possible  complication.  Choles- 
teatoma of  the  middle  ear  sometimes  extrudes  into  the 
meatus  and  may  simulate  or  complicate  the  affection  of 
the  meatus.  Epidermis  plugs  cannot  always  be  removed 
by  syringing  alone,  although  this  should  be  tried  first. 


422  DISEASES    OF   THE    EXTERNAL   EAR. 

They  can  be  softened  better  by  means  of  glycerin  than  by 
bicarbonate  of  sodium  solution.  When  difficult  to  detach 
and  requiring  the  use  of  instruments,  it  is  well  to  fill 
the  ear  with  carbolated  glycerin,  both  for  maceration 
and  protection  against  infection.  A  tooth-pick  dipped 
into  a  concentrated  solution  of  caustic  potash  may  be 
thrust  carefully  into  the  center  of  the  plug  in  order  to 
macerate  and  soften  it.  By  the  use  of  a  blunt  ear  spatula, 
blunt  broad  forceps,  blunt,  sometimes  even  sharp,  scoops, 
these  plugs  can  be  gradually  picked  out  in  the  course  of  a 
few  days  if  necessary.  If  the  skin  of  the  meatus  appears 
macerated  or  inflamed  after  removal  of  the  plug,  it  should 
be  brushed  with  nitrate  of  silver  solution  (lo  per  cent.) 
until  healthy.  When  this  is  done,  epidermis  plugs  are 
not  so  likely  to  recur  as  wax  plugs. 


CHAPTER   XXXIV. 

DISEASES  OF  THE   EXTERNAL   EAR. 

FOREIGN  BODIES.  OPERATIVE  DETACHMENT  OF  THE 
AURICLE.  TUMORS.  STENOSIS  OF  THE  MEATUS. 
INJURIES.     MYRINGITIS. 

336.  Foreign  bodies,  such  as  beads,  peas,  wads  of 
paper,  and  the  like,  get  into  the  external  meatus  mainly- 
through  the  pranks  of  children.  Cotton  and  gauze  are 
sometimes  forgotten  and  left.  A  variety  of  small  objects, 
sticks  of  wood,  and  so  on  get  in  by  accident,  and  insects 
— for  instance,  bedbugs  and  the  larvae  of  flies — have  been 
found  at  times.  As  long  as  the  foreign  body  is  not  sharp 
its  mere  presence  causes  no  annoyance  beyond,  perhaps, 
a  feeling  of  fulness,  and  it  leaves  no  consequences.  It  is 
the  traumatism,  especially  from  unskilful  attempts  at 
extraction,  which  is  to  be  feared.  The  inexperienced 
physician  cannot  be  warned  too  emphatically  that  it  is 
safer  to  leave  a  foreign  body  in  the  meatus  for  the  time 
being  than  to  take  the  chances  of  wounding  the  walls  or 
the  drumhead.  No  attempt  to  remove  a  foreign  body- 
should  be  made  unless  the  latter  is  seen.  If  it  be  covered 
by  wax,  the  removal  of  the  wax  is  in  order.  If  it  is  so 
small  as  to  be  hidden  in  the  deep  sinus  of  the  meatus  next 
to  the  membrana  tynipani,  it  will  probably  drop  out  when 
the  head  is  turned  to  the  side.  Hence  leisurely  inspection 
through  the  speculum  with  a  good  light  should  establish 
the  diagnosis  before  any  therapeutic  action  is  attempted. 
Prompt  action  is  only  required  if  traumatism,  either  in- 
cidental or  due  to  former  attempts  at  extraction,  has  led 
to  complications.  These  may  be  diffuse  inflammation  of 
the  walls  of  the  meatus  or  inflammatory  involvement  of 
the  middle  ear.  In  the  latter  case  extensive  traumatism 
involves  the  risk  of  extension  to  the  brain. 

423 


424  DISEASES    OF   THE    EXTERNAL   EAR. 

The  safest  way  to  remove  a  foreign  body  is  by  patient 
syringing  with  warm  water.  In  the  case  of  peas  or  beans, 
which  swell  when  moistened  with  water,  oil  or  alcohol 
may  be  used  for  syringing,  unless  they  are  freely  mobile 
and  can  be  made  to  drop  out  by  turning  the  head.  Live 
insects  may  be  dislodged  by  tobacco  smoke  or  chloroform 
vapor.  Impacted  objects  which  do  not  budge  on  syring- 
ing should  be  seized  with  the  utmost  care  with  a  small 
sharp  hook  or  a  flat  curet,  with  its  blunt  edge  turned 
toward  the  wall,  or  the  snare.  The  surgeon  should 
always  remember  not  to  push  the  object  deeper  into  the 
canal.  Forceps  of  any  kind  are  apt  to  do  this.  Good 
illumination  is  indispensable.  In  the  case  of  an  unruly 
child  anesthesia  may  prove  necessary.  If  the  attempted 
extraction  fails,  it  is  sometimes  better  to  desist  for  the 
time  as  long  as  there  are  no  urgent  symptoms.  Under 
the  use  of  carbolated  glycerin  moderate  swelling  of  the 
meatus  may  recede  sufficiently  to  permit  an  easier  ex- 
traction a  day  or  two  later. 

327.  When  other  methods  fail  and  urgent  symptoms 
indicate  prompt  interference,  the  auricle  and  cartilaginous 
meatus  are  to  be  detached  from  the  osseous  canal  in  order 
to  gain  access  to  its  depth.  The  typical  operation  is  done 
as  follows: 

Vertical  (slightly  curved)  incision  down  to  the  bone,  5 
mm.  behind  the  auricle  from  the  tip  of  the  helix  to  nearly 
the  tip  of  the  mastoid  process.  Compression  or  torsion 
of  bleeding  vessels.  Detachment  (by  means  of  an  ele- 
vator) of  the  periosteum  and  of  the  cartilaginous  meatus 
from  the  bone.  Transverse  (vertical)  section  through 
the  posterior  cutaneous  wall  of  the  osseous  meatus  with 
the  tenotome.  By  pulling  the  auricle  forward,  the  car- 
tilaginous meatus  is  almost  entirely  lifted  out  of  the 
osseous  canal,  which  is  now  accessible.  Good  illumina- 
tion without  reflecting  mirror  is  all  that  is  required.  If 
the  foreign  body  cannot  be  removed  by  reason  of  impac- 
tion, the  osseous  meatus  is  now  enlarged  by  chiseling 
away  its  posterior  wall  with  small  concave  gouges.   After 


TUMORS,  425 

completion  the  cartilaginous  meatus  and  auricle  are  re- 
placed and  the  external  wound  is  sutured.  If  the  poste- 
rior wall  has  been  chiseled,  the  integument  of  the  meatus 
is  slit  longitudinally  for  the  purpose  of  better  coaptation. 
The  meatus  is  then  packed  with  iodoform  gauze.  The 
operation  is  rarely  required,  except  in  the  case  of  com- 
plicating inflammation  of  the  middle  ear  or  shot  wounds. 

328.  Tumors  of  the  external  ear  or  of  any  part  of  the 
ear  are  not  common.  The  most  frequent  growth  of  the 
auricle  is  the  fibroma  or  keloid,  sometimes  the  consequence 
of  irritation  by  an  ear-ring.  Keloids  are  more  often  seen 
in  negroes.  Sebaceous  cysts  occur  mainly  on  the  concave 
side  of  the  auricle.  Cancer  and  lupus  are  rarely  seen  here. 
All  these  morbid  processes  present  no  peculiarities  dif- 
ferent from  those  in  other  localities. 

In  the  meatus  polypi  are  often  seen,  but  they  rarely 
spring  from  the  walls  of  the  meatus,  mostly  from  the  mid- 
dle ear,  and  will  be  treated  in  connection  with  chronic 
suppurative  otitis.  The  few  polypi  which  originate  from 
the  walls  of  the  meatus  must  be  considered  in  the  same 
manner  as  those  extruding  from  the  middle  ear.  The 
most  frequent  neoplasms  of  the  meatus  are  exostoses. 
They  may  grow  sufficiently  to  occlude  the  canal.  Some- 
times they  are  multiple.  They  are  of  ivory  hardness, 
and  must  be  removed  by  chiseling  through  the  healthy 
bone  around  them.  Their  discussion  can  be  combined 
with  that  of  stenosis  or  atresia  of  the  external  meatus. 

329.  Narrowing  or  occlusion  of  the  canal  may  be 
due  to  various  lesions.  Besides  circumscribed  exostoses, 
a  diffuse  hyperostosis  of  the  osseous  wall  or  at  least  of  a 
part  of  it  is  sometimes  seen,  especially  in  connection  with 
old  chronic  suppuration  of  the  middle  ear.  Cicatricial 
contraction  may  follow  an  ulcerative  process,  such  as 
corrosion  by  chemicals  or  burns  or  lupus,  or,  very  rarely, 
diphtheritic  inflammation  of  the  meatus.  It  may  also 
follow  faulty  healing  after  a  radical  mastoid  operation 
with  partial  removal  of  the  posterior  wall  of  the  meatus. 
Total  occlusion  of  the  canal  is  sometimes  seen  as  a  con- 


426  DISEASES    OF    THE    EXTERNAL    EAR. 

genital  condition,  either  in  the  form  of  a  membranous 
diaphragm,  or  as  total  obliteration  of  the  caliber.  The 
former  condition  is  recognizable  by  the  yielding  to  the 
probe,  while  hardness  of  the  obstruction  shows  it  to  be 
bony. 

Narrowing  of  the  meatus  requires  surgical  attention  if 
it  either  interferes  with  hearing  or  with  the  escape  of  the 
secretion  of  a  diseased  middle  ear.  The  latter  indication 
is  imperative.  Otherwise  it  may  not  be  necessary  to 
interfere.  Mechanical  dilatation  and  small  operations 
are  useless.  Drilling  by  means  of  hand  drills  or  burrs 
run  by  a  dental  motor  or  chiseling  is  permissible  only 
on  the  anterior  wall  and  only  within  the  length  of  the 
meatus.  Any  encroachment  toward  the  drumhead  in- 
volves risk.  In  the  case  of  exostosis  or  diffuse  hypertrophy 
of  the  posterior  wall  the  proper  method  is  chiseling  after 
detachment  of  the  auricle.  The  hard  growths  can  be 
shelled  out  by  gouging  through  the  normal  bone.  When 
working  on  the  posterior  wall  it  must  be  remembered 
that  in  the  vicinity  of  the  drumhead  there  is  danger  to 
the  facial  nerve  and  semicircular  canals.  Congenital 
occlusions  are  easily  dissected  out  if  membranous.  In 
the  case  of  total  obliteration  of  the  canal  an  operation  is 
risky  and  of  questionable  utility.  It  should  not  even  be 
considered  unless  tests  with  tuning-forks  establish  the 
integrity  of  the  internal  ear  on  that  side  beyond  ques- 
tion. 

330.  Under  th«  head  of  accidents  to  the  ear  frost-bites 
must  be  mentioned  as  the  most  common.  Congelation 
of  the  helix  or  of  the  lobule  causes  a  blanching,  followed 
by  persistent  lividity.  The  popular  practice  of  rubbing 
frozen  ears  with  snow  in  order  to  thaw  them  gradually  is 
probably  founded  on  experience.  The  congestive  reaction 
after  a  frost-bite  may  last  a  long  time  and  is  apt  to  return 
upon  slight  exposure.  Nothing  can  be  done  for  it  beyond 
protection  in  cold  weather. 

331.  The  most  frequent  injury  to  the  ear  is  that  result- 
ing from  a  blow.     It  may  lead  to  ringing  and  slight  deaf- 


MYRINGITIS.  427 

ness,  without  visible  lesion  of  the  drumhead.  This  may 
be  due  to  a  hemorrhage  or  merely  a  concussion  of  the 
labyrinth.  The  effects  pass  off  in  a  few  days  at  the  most, 
unless  the  ear  was  previously  the  seat  of  a  catarrhal 
process  which  is  sometimes  considerably  aggravated.  A 
blow  may  also  cause  a  rupture  of  the  drumhead.  The 
same  lesion  is  sometimes  the  result  of  explosions,  and 
necessarily  foHows  any  direct  traumatism  by  pointed 
implements.  Traimiatic  ruptures  of  the  membrana 
tympani  are  linear  and  show  bloody  suffusion  of  the 
edges.  The  hearing  is  temporarily  impaired.  They 
usually  heal  without  reaction  if  not  irritated  or  infected 
by  injudicious  treatment.  Nothing  beyond  rest  of  the 
parts  is  called  for.  Syringing  and  applications  are  at 
least  useless,  if  not  injurious. 

More  serious  is  any  traumatism  of  the  drumhead  which 
leads  to  bruising  as  well  as  to  rupture.  This  may  hap- 
pen from  the  entrance  of  tree  twigs  or  stalks  or  from 
unskilful  manipulations  in  the  meatus.  The  damaged 
drumhead  often  sloughs  for  a  number  of  days  with  gradual 
enlargement  of  the  perforation,  and,  of  course,  with  sup- 
puration of  the  middle  ear.  The  treatment  in  such  cases 
should  be  that  of  acute  otitis  (T[  360). 

When  violence  causes  a  fracture  at  the  base  of  the  skull  it 
is  apt  to  rupture  the  drumhead  as  well.  .  The  diagnostic 
sign  of  this  accident  is  the  discharge  of  cerebrospinal 
fluid,  more  or  less  bloody,  through  the  meatus.  If  the 
patient  survives,  severe  suppurative  middle-ear  disease  is 
apt  to  follow.  It  should  be  guarded  against  in  such  cases 
by  immediate  asepsis  of  the  meatus  with  carbolic  acid 
solution  and  the  introduction  of  sterile  gauze  drains  as 
in  the  treatment  of  purulent  otitis. 

33a.  Myringitis,  inflammation  limited  to  the  mem- 
brana tympani,  is  a  rare  occurrence  which  the  writer  has 
never  seen  in  the  acute  form  unless  of  traumatic  origin. 
It  is  described  by  Politzer  as  a  formation  of  small  circum- 
scribed blood  blisters,  serous  vesicles,  or  even  minute 
abscesses  on   the  cutaneous  side  of  the   drumhead.     It 


428  DISEASES    OF   THE    EXTERNAL    EAR. 

causes  more  or  less  shooting  pain,  with  scarcely  any  im- 
pairment of  hearing,  and  heals,  as  a  rule,  within  a  few 
days.  The  vesicles  may  be  pricked  with  a  needle  and 
the  membrane  dusted  with  boric  acid. 

Chronic  inflammation  limited  to  the  drumhead  is 
not  quite  so  rare  as  acute  myringitis,  but  is,  as  a  rule,  a 
secondary  affection  resulting  from  eczema  or  a  desquama- 
tive dermatitis  of  the  meatus,  or  is  a  sequel  to  suppurative 
inflammation  of  the  middle  ear.  The  drumhead  appears 
cloudy,  and  its  surface  macerated  and  sometimes  covered 
with  moist  .scales.  Politzer  describes  a  papillary  form  in 
which  the  membrane  is  partly  covered  with  minute  granu- 
lations. The  disease  produces  very  little  disturbance 
beyond  slight  discomfort  and  itching.  After  cleansing, 
boric  acid  powder  may  be  blown  in.  If  this  produces  a 
temporary  watery  discharge  or  if  no  improvement  follows 
within  a  few  days,  a  lo  per  cent,  solution  of  nitrate  of 
silver  can  be  tried.  For  the  papillar\'  form  Politzer 
recommends  brushing  with  tincture  of  chlorid  of  iron. 


CHAPTER   XXXV. 

DISEASES  OF   THE   MIDDLE   EAR. 

CATARRH   OF  THE  EUSTACHIAN  TUBE.-SEROUS 
CATARRH   OF  THE  MIDDLE  EAR. 

333.  Diseases  of  the  middle  ear  are  divided  into 
affections — {a)  without  and  {b)  with  suppuration.  The 
division  is  justified  by  the  difference  in  the  prognosis  and 
therapeutic  indication  of  the  two  groups.  The  non-sup- 
purative  group  inclu^des — 

Catarrh  of  the  Eustachian  tube  ; 

Serous  or  exudative  catarrh  of  the  middle  ear ; 

Plastic  or  adhesive  inflammation  of  the  middle  ear  ; 

Sclerosis. 

CATARRH  OF  THE  EUSTACHIAN  TUBE. 

Inflammatory  obstruction  of  the  Eustachian  tube  ac- 
companies all  inflammatory  affections  of  the  middle  ear. 
But  as  a  lesion  limited  to  the  tube,  without  primary  dis- 
ease of  the  middle  ear,  it  is  not  commonly  seen  in  adults, 
though  very  common  in  childhood.  It  is  due  in  most 
instances  to  the  presence  of  an  enlarged  pharyngeal  ton- 
sil (adenoid  vegetations)  and  occurs  in  the  course  of  sub- 
acute inflammatory  processes  involving  the  nasopharynx. 
In  rare  instances  it  is  the  result  of  an  acute  nasal  catarrh 
without  permanent  enlargement  of  the  pharyngeal  tonsil, 
and  under  these  conditions  it  is  sometimes  seen  during 
adolescence.  Any  systemic  disease  accompanied  by  nasal 
or  pharyngeal  inflammation  may  be  the  remote  cause  of 
Eustachian  occlusion. 

The  only  manifest  symptom  of  Eustachian  obstruction 
in  children  is  reduced  hearing  acuity.  The  impairment 
begins  either  acutely  or,  as  a  rule,  more  gradually,  accord- 

4?9 


430  DISEASES    OF    THE    MIDDLE    EAR. 

ing  to  the  intensity  of  the  nasopharyngeal  inflammation. 
It  remains  more  or  less  stationary  for  a  variable  or  even 
indefinite  period  of  time,  and  does  not  usually  reach  any 
high  degree.  Hypertrophy  of  the  pharyngeal  tonsil  pre- 
vents, as  a  rule,  complete  spontaneous  recovery,  or  leads 
to  frequent  relapses  if  the  hearing  has  been  restored  tem- 
porarily. When  the  pharynx  becomes  normal  after  a 
transient  catarrh,  the  Eustachian  affection  disappears 
entirely.  The  impairment  of  hearing  is  sometimes  so 
slight  that  it  is  detected  only  by  the  child's  inattention. 
Tests  show  that  there  is  reduction  of  air-conduction  only, 
not  of  bone-conduction.  Both  ears  are  always  involved, 
though  not  necessarily  alike. 

Adults  complain  of  a  sense  of  fulness  in  the  ears.   Young 
children  either  do  not  feel  or  do  not  notice  this  sensation. 


Fig.   126. — Retracted  membrana  tympani  in   Eustachian  catarrh,  with  serous 
fluid  in  the  middle  ear.     The  level  of  the  fluid  is  marked  by  a  straight  line. 

Sometimes  they  admit  it  after  being  relieved  by  inflation. 
Occasionally  sharp  earache — especially  one-sided — is  com- 
plained of,  most  likely  during  the  night.  Although  the 
cases  with  this  pain  follow  the  same  course  and  yield 
equally  rapidly  to  treatment  as  typical  painless  Eusta- 
chian catarrh,  the  pain  is  probably  due  to  some  slight 
lesion  in  the  middle  ear.  This  view  is  supported  by  the 
presence  of  vascular  streaks — congested  vessels — along 
the  handle  of  the  hammer,  which  are  not  seen  in  ordinary 
Eustachian  catarrh. 

The  drumhead  is  normal  in  color  and  luster,  but  is 
distinctly  drawn  in.  The  handle  of  the  hammer  hence 
appears  foreshortened  (compare  Fig.  2,  Plate  II.).  In 
some  instances,  but  not  as  a  rule,  an  effiision  of  clear 
serum  can  be  seen  through  the  drumhead  (Fig.    126). 


CATARRH    OF    THE    EUSTACHIAN    TUBE.  43 1 

334.  A  single  successful  inflation  of  the  middle  ear  by 
Politzer's  method  or  by  means  of  the  catheter  removes 
all  results  of  the  Eustachian  obstruction,  except  in  long- 
standing disease  with  secondary  lesions.  The  hearing 
becomes  normal  at  once  or  in  a  few  minutes;  the  fulness, 
if  felt  before,  disappears,  and  the  drumhead  regains  its 
normal  position.  If  fluid  is  visible  through  the  mem- 
brane, it  is  apt  to  be  churned  into  foam,  and  air-bubbles 
can  now  be  seen.  The  fluid  disappears  gradually  by 
absorption. 

Although  there  is  but  little  opportunity  to  study  the 
pathology  of  simple  Eustachian  catarrh  in  the  dead-room, 
its  nature  and  mechanism  are  clearly  understood.  Indeed, 
this  knowledge  is  the  key  to  our  understanding  and  treat- 
ment of  all  the  diseases  of  the  middle  ear  which  are  com- 
plicated by  Eustachian  obstruction.  The  obstruction  is 
due  to  swelling  and  venous  engorgement  of  the  mucous 
membrane  at  the  pharyngeal  end  of  the  Eustachian  tube. 
The  immediate  and  often  permanent  results  of  infla- 
tion leave  no  doubt  that  the  swelling  depends  mainly 
on  serous  infiltration — inflammatory  edema — of  the  Eu- 
stachian lining.  The  imperfect  postrhinoscopic  view, 
which,  as  a  rule,  is  all  that  can  be  obtained  in  children 
with  adenoids,  shows  no  gross  change  at  the  Eustachian 
orifice.  The  inflammatory  process  itself  does  not  always 
extend  into  the  tube.  The  assumption  of  some  writers 
that  adenoid  vegetations  can  block  the  tube  mechanically 
is  not  supported  by  actual  examination  of  the  naso- 
pharynx in  the  living  or  dead.  When  the  Eustachian 
channel  remains  closed  without  periodic  ventilation  of 
the  drum  cavity,  the  air  confined  in  the  middle  ear  is 
gradually  absorbed  by  the  circulating  blood  in  the  vessels. 
The  tension  of  the  air  in  the  drum  cavity  hence  falls  below 
the  pressure  of  the  external  atmosphere.  As  a  result,  the 
greater  pressure  on  the  external  surface  of  the  membrana 
tympani  forces  this  membrane  inward.  This  faulty  posi- 
tion of  the  drumhead  is  recognizable  by  the  obliquity  of 
the  manubrium  and  the  elongation  of  the  triangular  light 


432  DISEASES    OF    THE    MIDDLE    EAR. 

spot.  This  pressure  upon  the  membrane  is  transmitted 
through  the  ossicles  and  oval  window  to  the  contents  of 
the  labyrinth,  as  can  be  shown  by  experimentation  with 
a  fresh  specimen.^ 

The  reduction  of  hearing  is  accounted  for  partly  by 
the  increased  labyrinthine  pressure,  partly  by  the  press- 
ure exerted  upon  the  chain  of  ossicles,  which  impairs 
their  ability  to  conduct  sound-waves.  The  diminished 
air-pressure  in  the  tympanic  cavity  permits  abnormal 
engorgement  of  the  blood-vessels,  which  presumably  ex- 
tends into  the  Eustachian  tube  and  exerts  an  unfavor- 
able influence  upon  the  morbid  condition  at  its  pharyn- 
geal end.  High  degrees  of  this  circulatory  disturbance 
lead  finally  to  an  effusion  of  serum  into  the  drum  cavity. 
This  is  not  an  inflammatory  exudate,  but  merely  a  trans- 
udate of  the  fluid  of  the  blood.  When  tested  after  aspi- 
ration through  a  puncture  of  the  drumhead,  it  has  been 
found  free  from  micro-organisms.  It  is  evident  that  a 
single  inflation  of  the  middle  ear  will  repair  all  the 
functional  disturbances  caused  by  Eustachian  obstruction, 
as  long  as  there  are  no  structural  changes  present  in  the 
middle  ear.  When,  however,  the  retraction  of  the  drum- 
head has  continued  for  long  periods  of  time, — variable 
with  the  individual, — secondary  changes  do  occur.  The 
joint  between  hammer  and  anvil  becomes  fixed  by  the 
long-continued  retraction  of  the  handle,  the  faulty  posi- 
tion of  membrana  tympani  and  ossicles  becomes  perma- 
nent, and  some  impairment  of  sound-conduction  remains, 
with  irreparable  damage  to  the  hearing. 

The  treatment  of  Eustachian  "  catarrh  "  by  a  single  in- 
flation results  in  a  permanent  cure  in  those  instances  in 
which  the  inflammatory  process  in  the  nasopharynx  has 
subsided  without  leaving  permanent  lesions.  The  infla- 
tion anticipates  the  natural  cure.  When  the  Politzer 
method  fails  on  account  of  the  valve-like  action  of  the 
*' soggy"    Eustachian  mucous  membrane,  it  is  best   to 

'  By  putting  a  capillary  tube  into  a  semicircular  canal  and  observing  the 
rise  of  fluid  in  it  upon  pressing  the  drumhead  inward. 


SEROUS    OR    EXUDATIVE    CATARRH    OF   THE    MIDDLE    EAR.      433 

inflate  by  means  of  the  catheter.  Sometimes  a  few 
repetitions  are  necessary  in  the  course  of  a  few  days. 
But  whenever  structural  changes  of  a  permanent  nature 
exist  in  the  nasopharynx,  such  as  hypertrophy  of  the 
pharyngeal  tonsil,  enlargement  with  chronic  inflamma- 
tion of  the  faucial  tonsils  or  purulent  rhinitis,  the  infla- 
tion gives  relief  only  for  a  variable  but  short  period,  with 
certainty  of  relapse.  A  radical  cure  in  such  instances  is 
obtained  only  after  proper  treatment  of  the  pharyngeal 
or  nasal  affection. 


SEROUS  OR  EXUDATIVE  CATARRH  OF  THE  MIDDLE  EAR. 

335.  Catarrh  of  the  middle  ear  with  effusion  of  fluid 
is  found  in  nearly  lo  per  cent,  of  ear  patients.  It  is 
much  more  common  after  puberty  than  in  childhood. 
In  young  children  predisposed  to  ear  disease  by  an  en- 
larged pharyngeal  tonsil  or  other  nasopharyngeal  lesions 
low  grades  of  inflammation  do  not  usually  extend  far 
beyond  the  Eustachian  orifice,  while  severer  forms  of 
disease  lead  to  purulent  otitis.  Catarrhal  otitis  is  double- 
sided  in  nearly  three  instances  out  of  four,  but  quite 
often  one  ear  suffers  so  little  that  the  patient  complains 
only  of  the  other. 

The  disease  begins  acutely  with  a  "full"  feeling  in 
the  ear  or  through  the  head.  The  patient  says  the  ear 
is  "closed."  In  children  earache  may  be  present;  in 
adults  it  is  neither  common  nor  severe  if  present.  There 
may,  however,  be  some  pain  on  swallowing.  Almost 
from  the  start  deafness  is  complained  of.  But,  as  a  rule, 
this  is  not  so  excessive  on  actual  test  as  the  patient 
claims.  He  is  apt  to  be  misled  as  to  his  hearing  ability 
by  the  stuffy  feeling.  Tests  show  great  differences  in 
the  reduction  of  hearing  in  different  cases,  from  barely- 
perceptible  impairment  to  difficulty  in  understanding 
loud  speech  close  to  the  ear.  Bone-conduction  is  always 
intact.  The  patient's  own  voice  sounds  muffled  to  him. 
Noises  in  the  ear  may  accompany  serous  catarrh,  but  do 

28 


434  DISEASES    OF    THE    MIDDLE    EAR. 

not  usually  cause  much  anno\ance,  especially  in  the 
beginning. 

Since  the  objective  disturbances  are  in  part  due  to  the 
presence  of  fluid  in  the  middle  ear,  the  shifting  of  the 
level  of  the  fluid  on  changing  the  position  of  the  head 
may  make  a  marked  change  in  the  discomfort,  sometimes 
for  the  better,  sometimes  for  the  worse. 

Dizziness  is  occasionally  a  distressing  complaint.  There 
are  some  exceptional  instances  on  record  in  which  grave 
cerebral  disease  was  simulated  by  acute  catarrh  of  the 
middle  ear,  especially  in  infants.  Different  otologists 
have  seen  a  condition  of  coma  or  stupor,  sometimes  with 
convulsions,  promptly  relieved  by  the  treatment  of  an 
acute  catarrhal  otitis.  It  is,  therefore,  sound  practice  to 
examine  the  ears  in  every  case  of  obscure  brain  symp- 
toms, especially  in  children. 

The  course  of  catarrhal  otitis  is  variable  and  depends 
a  good  deal,  but  not  exclusively,  on  the  condition  of  the 
nose  and  pharynx.  Very  mild  cases  without  pennanent 
nasopharyngeal  lesions  recover  spontaneously  in  two  to 
three  weeks.  In  more  severe  instances  complete  recov- 
ery is  exceptional  unless  as  the  result  of  treatment. 
Without  sufficient  treatment  the  more  acute  symptoms 
may  diminish,  but  complete  recovery  does  not  take  place. 
Either  some  exudate  remains  in  the  drum  cavity  and  the 
disease  becomes  subacute,  with  occasional  acute  relapses, 
or  the  changes  in  the  mucous  membrane  assume  a  plastic 
character  and  the  affection  changes  gradually  to  the  type 
of  chronic  adhesive  middle-ear  disease.  The  former 
class  of  cases  offer  a  much  better  prognosis  in  case  of 
late  treatment  than  the  latter.  A  serious  obstacle  to 
recovery  are  permanent  nasopharyngeal  lesions,  espe- 
•cially  nasal  stenosis. 

336.  The  lesions  found  in  accidental  autopsies  of  ca- 
tarrhal otitis  are  congestion  and  inflammatory  swelling  of 
the  mucous  membrane,  with  fluid  exudation.  The  swell- 
ing may  either  be  trivial  or  may  be  so  intense  as  to  obliter- 
ate part  of  the  drum  cavity.     It  may  be  confined  to  small 


SEROUS  OR  EXUDATIVE  CATARRH  OF  THE  MIDDLE  EAR.   435 

areas,  especially  on  the  internal  wall  or  around  the  artic- 
ulation of  the  ossicles,  or  it  may  be  diffuse  and  even 
extend  into  the  mastoid  antrum,  the  lining  of  which  is 
at  least  congested.  The  membrana  tympani  is,  as  a 
rule,  but  little  altered.  The  swelling  is  due  to  infiltra- 
tion of  the  mucous  membrane  with  serum  and  round 
cells.  The  epithelium  may  be  partly  defective.  Where 
the  tumefaction  of  the  mucous  membrane  brings  differ- 
ent parts  of  its  surface  in  contact  with  each  other,  adhe- 
sions may  form  which  persist  after  the  swelling  has  sub- 
sided. The  movements  of  the  ossicles  may  thus  become 
permanently  hampered.  The  swelling  extends  into  the 
Eustachian  tube,  but  not  necessarily  far  beyond  its  tym- 
panic end.  Quite  often  the  middle  or  even  the  greater 
portion  of  the  Eustachian  channel  shows  normal  lining 
and  structure.  The  pharyngeal  end,  however,  is  fre- 
quently found  in  a  state  of  inflammatory  swelling.  Yet 
this  condition  is  generally  not  recognizable  on  postnasal 
examination  during  life.  The  fluid  in  the  drum  cavity, 
variable  in  amount,  is  a  more  or  less  viscid,  even  slightly 
purulent,  mucus.  On  opening  the  cavity  it  is  sometimes 
seen  to  adhere  very  firmly  to  the  walls.  It  may  be  so 
scant  in  amount  as  not  to  extend  above  the  inferior  rim 
of  the  membrana  tympani,  and  hence  may  not  be  visible 
through  the  membrane.  Upon  withdrawal  of  the  exu- 
date by  paracentesis  it  has  been  found  to  contain  staphy- 
lococci and  streptococci.  The  same  microbes  are  also 
found  in  part  of  the  cases  of  purulent  otitis.  Why  they 
should  lead  to  a  superficial  catarrhal  inflammation  in  one 
case  and  to  a  suppurative  process  with  tendency  to  in- 
volve the  deeper  tissues  in  another  is  not  definitely 
known. 

Catarrh  of  the  middle  ear  is  probably  always  secondary 
to  an  inflammation  in  the  nose  or  pharynx.  The  primary 
trouble  may  have  ceased  by  the  time  the  ear  is  examined. 
Although  the  ear  may  become  involved  in  the  course 
of  an  uncomplicated  coryza  of  sufficient  intensit}',  the 
majority   of   cases   present    more   permanent  structural 


43^  DISEASES    OF    THE    MIDDLE    EAR. 

changes  in  the  nose  or  pharynx,  which  must  be  con- 
sidered important  determining  conditions  in  extension 
of  disease  to  the  ear.  In  children  the  most  important  of 
these  is  hypertrophy  of  the  pharyngeal  tonsil.  After 
adolescence  this  lesion,  even  when  it  does  not  recede, 
becomes  less  of  a  menace  to  the  ear.  In  adults  stenosis 
of  the  nose  deserves  especial  attention  as  a  factor  in  the 
production,  as  well  as  in  the  perpetuation,  of  aural 
catarrh.  Subacute  exacerbation  of  a  diffuse  purulent 
rhinitis  in  the  course  of  chronic  rhinitis  or  sinuitis  is 
oftener  the  starting-point  than  uncomplicated  primary 
coryza.  Ozena  is  not  a  common,  but  sometimes  an  im- 
portant, primary  affection.  Occasionally  large  tonsils 
seem  to  be  of  influence. 

Exudative  catarrh  occurs  not  only  in  the  typical  un- 
complicated form,  but  also  in  subacute  spells  of  exacer- 
bation in  the  course  of  chronic  adhesive  otitis.  Details 
regarding  this  form  of  disease  will  be  found  in  the  de- 
scription of  adhesive  otitis. 

337.  The  diagnosis  of  exudative  catarrh  of  the  middle 
ear,  suggested  by  the  sudden  impairment  of  hearing  with 
feeling  of  obstruction,  is  based  on  the  evidences  of  intra- 
tympanic  exudate  with  swelling  of  the  mucous  lining  of 
the  drum  cavity.  The  membrana  tympani  may  show 
but  little  anomaly  at  first.  Some  vascular  streaks  may 
run  parallel  to  the  handle  of  the  hammer,  but  a  diffuse 
redness  is  foreign  to  this  disease.  The  Eustachian 
obstruction,  which  is  rarely  absent,  causes  within  a  short 
time  typical  sinking  in  or  retraction  of  the  drumhead,  as 
described  under  the  head  of  Eustachian  catarrh.  The 
handle  of  the  hammer  appears  foreshortened,  on  account 
of  increased  obliquity,  the  triangular  light  spot  elongated. 
The  luster  of  the  membrane  is  apt  to  become  dimmed  in 
the  course  of  the  disease.  In  case  of  long  duration  the 
translucency  of  the  drumhead  diminishes.  Exudation  in 
the  middle  ear  can  be  seen  through  the  drumhead  when- 
ever it  reaches  appreciably  above  its  inferior  rim.  Very 
often  this  is  not  the  case.    It  requires  strong  illumination 


SEROUS  OR  EXUDATIVE  CATARRH  OF  THE  MIDDLE  EAR.   437 

in  order  to  see  it.  The  level  of  the  fluid  is  marked  by  a 
line  across  the  drumhead,  usually  dark  ;  sometimes,  how- 
ever, a  bright  reflection  (compare  Fig.  3,  Plate  11. ),  The 
line  may  be  low  down  or  high  up.  On  account  of  the 
irregular  shape  of  the  membrane  the  line  indicating  the 
level  of  the  fluid  does  not  necessarily  appear  straight,  as  it 
really  is,  but  may  seem  curved  or  bent.  Below  the  level 
of  the  fluid  the  membrana  tympani  is  darker,  yellowish 
green  or  yellowish  red.  When  the  fluid  can  be  recog- 
nized, the  level  is  seen  to  shift  with  inclination  of  the 
head,  while  slowness  of  this  motion  indicates  the  vis- 
cidity of  the  exudation. 

The  Eustachian  obstruction  is  apparent  in  the  Valsalva 
experiment,  but  is  not  always  revealed  by  inflation 
according  to  Politzer  or  by  the  catheter.  On  auscultation 
during  the  entrance  of  air  a  bubbling  sound  indicates 
the  presence  of  mucus  in  the  tube  or  fluid  in  the  drum 
cavity.  The  sound  varies  from  a  coarse  to  a  very  fine 
rale.  Its  quality  can  be  learned  only  by  practice  and  not 
by  description.  Eustachian  narrowness  is  revealed  by  a 
change  from  the  normal  faint  clear  blowing  sound  to  a 
hiss  or  even  a  squeak.  As  a  rule,  the  sound  heard  signi- 
fies but  moderately  impeded  entrance  of  air,  except  in 
some  protracted  forms  verging  toward  chronicity. 

Of  much  diagnostic  and  prognostic  importance  is  the 
subjective  effect  of  inflation.  In  catarrh  of  the  middle 
ear  inflation  improves  the  hearing  and  reduces  the  fulness 
invariably,  but  to  a  very  variable  extent  in  diflferent  cases. 
For  the  conditions  described  in  the  chapter  on  Eustachian 
catarrh  (1  334)  are  always  present — viz.,  diminished 
patency  of  the  Eustachian  passage,  hence  less  regular  or 
even  abolished  ventilation  of  the  drum  cavity,  reduction 
of  intratympanic  air-tension  by  absorption,  unbalanced 
pressure  of  the  external  atmosphere  upon  the  membrane 
transmitted  through  the  ossicles  to  the  labyrinth,  and 
congestion  of  the  intratympanic  blood-vessels.  While 
all  these  mechanical  disturbances  yield  to  inflation,  there 
exists,  besides,   inflammatory  swelling  of  the  tympanic 


43^  DISEASES    OF   THE    MIDDLE    EAR. 

lining,  causing  more  or  less  rigidity  of  the  ossicular  artic- 
ulations, as  well  as  a  variable  amount  of  fluid  exudate. 
These  latter  changes  are  not  influenced  immediately  by 
inflation.  Hence  the  degree  of  immediate  improvement 
resulting  from  artificial  ventilation  through  the  tube  is 
inversely  proportionate  to  the  extent  of  the  morbid 
changes  in  the  drum.  In  some  instances  inflation  is 
followed  only  gradually  by  an  increasing  improvement  in 
hearing  and  comfort  until  the  full  benefit  is  obtained  some 
hours  later.  The  effect  of  Eustachian  ve»tilation  is  not 
limited  to  the  prompt  relief  of  the  mechanical  anomaly. 
For  by  restoring  the  normal  air-pressure  in  the  drum  an 
important  factor  in  the  maintenance  of  vascular  engorge- 
ment is  eliminated.  There  is  every  reason  to  assume  that 
in  the  ear,  as  elsewhere,  vascular  congestion  of  mechani- 
cal origin  interferes  with  the  normal  resolution  of  an 
inflammatory  process.  While  in  Eustachian  catarrh  a 
single  inflation  ends  all  disease  manifestations,  the  effect 
of  an  inflation  is  only  temporary  when  there  is  disease  in 
the  middle  ear  itself.  The  greater  the  immediate  effect, 
the  longer  it  will  persist  and  the  less  complete  will  be  the 
return  of  the  previous  symptoms.  But  in  any  case  the 
effect  of  inflation  begins  to  decline  in  the  course  of  a 
day. 

338.  The  treatment  hence  consists  in  the  repetition  of 
inflations  at  least  once  a  day.  In  the  mildest  case  com- 
plete recovery  can  thus  be  obtained  in  about  eight  to  ten 
days.  Inflation  is  often  more  efiicient  by  means  of  the 
catheter  than  by  the  Politzer  method,  as  judged  by  the 
immediate  result.  The  Politzer  bag  may,  however,  be 
intrusted  to  the  patient's  hands,  if  necessary,  though,  as 
a  rule,  it  is  not  to  the  patient's  benefit  to  expect  him  to 
carry  out  any  part  of  the  treatment  to  which  the  surgeon 
ought  to  attend.  Eustachian  inflation  generally  stops 
promptly  any  earache  in  the  earlier  course  of  middle-ear 
catarrh.     The  pain  can  also  be  controlled  by  antipyrin. 

In  the  less  favorable  instances  the  benefit  of  inflation 
is  nearly  or  wholly  lost  within  twenty-four  hours.    There 


SEROUS    OR    EXUDATIVE    CATARRH    OF    THE    MIDDLE    EAR.      439 

may  even  be  occasional  exacerbations  in  spite  of  treat- 
ment. In  such  cases  it  is  best  to  advise  the  patient  to 
use  the  Politzer  bag  several  times  daily.  Extensive 
trials  have  been  made  to  increase  the  effect  of  inflation 
upon  the  absorption  of  the  inflammatory  swelling  and  of 
the  exudate  by  adding  the  vapor  of  iodin,  chloroform,  or 
oil  of  turpentine,  or  finely  divided  chlorid  of  ammonium, 
or  hot  air  (1  315).  It  is  very  difficult  to  judge  the  efficacy 
of  these  measures  in  a  given  case,  or  even  in  a  series  of 
cases,  on  account  of  the  positive,  but  somewhat  variable, 
influence  of  the  inflation  itself,  particularly,  however,  on 
account  of  the  impossibility  of  foretelling  accurately  the 
course  of  an  individual  case.  It  cannot  be  said  of  any 
one  form  of  vapor  application  that  it  has  received  decided 
praise  by  many  except  the  original  author.  While  it 
would  be  unjust  to  deny  the  utility  of  vapor  inflations 
entirely  or  to  refuse  them  some  trial,  it  cannot  be  said 
that  by  their  employment  results  can  be  obtained  which 
are  not  possible  without  them.  Chlorid  of  ammonium 
deserves  perhaps  trial  more  than  any  other  substance. 

The  injection  of  a  few  drops  of  fluid  into  the  tube 
through  the  catheter  must  be  spoken  of  with  less  reserve 
(nitrate  of  silver  solution  2  per  cent,  or  zinc  sulphate 
solution  0.5  to  I  per  cent).  Its  benefits  are,  at  the  best, 
doubtful.  A  few  drops  blown  in  do  not  penetrate  beyond 
the  tube,  which  is  usually  not  diseased  throughout  its 
middle  half.  A  larger  quantity  may  cause  and  has 
caused  suppurative  otitis. 

When  fluid  exudate  persists  in  the  drum  without 
being  absorbed  and  the  disease  is  thus  prolonged,  it 
may  be  removed  by  a  paracentesis  (1  316).  It  is  only 
in  a  small  minority  of  cases  of  exudative  catarrh  that 
paracentesis  is  indicated,  but  when  called  for  it  is  of 
decided  benefit.  When  done  aseptically,  it  causes  no 
unpleasant  consequences.  After  making  a  free  inci- 
sion the  exudate  is  blown  out  by  a  Politzer  inflation. 
If  viscid,  it  may  be  seen  adhering  to  the  wound. 
Boric   acid    is    insufflated   lightly,    and   a   piece   of  ab- 


440  DISEASES    OF    THE    MIDDLE   EAR. 

sorbent  gauze  is  left  in  the  meatus  to  absorb  the  fluid. 
Syringing  must  be  strictly  omitted  after  paracentesis. 
On  account  of  the  high  position  of  the  tympanic  open- 
ing of  the  Eustachian  tube  fluids  in  the  drum  do  not 
escape  through  the  tube,  except  as  the  result  of  overflow. 
Suction  through  a  flexible  tube  pushed  in  through  the 
catheter  is  hence  irrational.  Exudates  disappear  by 
absorption  when  the  tympanic  mucous  membrane  is  not 
too  much  diseased.  But  the  presence  of  the  exudate 
itself  keeps  up  the  inflammation  of  the  mucous  mem- 
brane. 

The  only  other  direct  mode  of  treatment  which  can 
exert  an  unmistakable  though  feeble  influence  upon  aural 
catarrh  is  pneumatic  massage  (1  313).  It  is  of  most  ser- 
vice after  the  acuteness  of  the  process  begins  to  decline. 

The  persistence  of  catarrhal  otitis  in  spite  of  local  treat- 
ment is  due  in  many  cases  to  the  persistence  of  the  nasal 
or  pharyngeal  condition  which  started  it.  It  must  be 
remembered  that  the  direct  cause  of  extension  to  the  ear 
is  the  nasopharyngeal  inflammatory  process.  If  this  has 
subsided  spontaneously,  no  nasal  treatment  is  called  for. 
But  if  the  inflammation  of  the  upper  air-passages  remains, 
its  treatment  produces  a  beneficial  efiect  upon  the  ear 
proportionate  to  its  influence  upon  the  nose  or  throat. 
In  proportion  as  we  succeed  in  reducing  purulent  secre- 
tion and  turgescence  of  the  nasal  cavernous  tissue  we  will 
find  an  improvement  in  the  ear.  If  the  disease  in  the 
nose  and  pharynx  can  be  made  to  yield  to  sprays,  the 
douche,  and  medicinal  applications,  the  aural  lesion  im- 
proves correspondingly.  But  if  the  persistence  of  the 
nasopharyngeal  inflammation  depends  on  the  presence  of 
permanent  structural  changes,  such  as  stenosis  due  to  sep- 
tum irregularities,  or  hypertrophy  of  mucous  membrane 
or  of  cavernous  tissue,  or  pharyngeal  adenoids,  operative 
treatment  is  required  in  order  to  stop  the  morbid  process 
both  in  the  respiratory  passages  and  in  the  ear.  It  does 
happen  at  times  that  the  nasopharyngeal  inflammation 
recovers  completely  in  spite  of  a  stenosis,  and  in  such  a 


SYPHILITIC    CATARRH    OF    THE    MIDDLE    EAR.  44 1 

case  the  ear  will  also  recover  without  nasal  operation,  but 
relapses  are  to  be  feared.  On  the  other  hand,  our  present 
means  of  treatment  of  nasal  and  pharyngeal  diseases  are 
not  infallible,  and  hence  a  catarrhal  otitis  may  drag  on  in 
spite  of  nasal  treatment. 

Aural  catarrh  will  occasionally  prove  obstinate,  even 
after  disappearance  of  the  nasopharyngeal  affection.  Re- 
covery depends  on  the  normal  resisting  power  of  the 
tissues.  This  may  be  enfeebled  by  a  variety  of  other  dis- 
turbances of  the  system — for  instance,  anemia,  intestinal 
derangement,  etc.  Hence  proper  hygienic  management 
must  not  be  overlooked. 

339*  Syphilitic  Catarrh  of  the  Middle  Kar. — Vari- 
ous observers  have  described  occasional  instances  of 
severe  middle-ear  affections  apparently  due  to  syphilis,  but 
neither  their  discordant  reports  nor  a  few  scant  autopsies 
suffice  to  establish  a  definite  clinical  type.  I  have  per- 
sonally seen  some  instances  of  a  form  of  middle-ear  affec- 
tion which  seemed  to  me  peculiar  to  syphilitic  patients. 
It  was  apparently  a  severe  catarrhal  inflammation  of 
moderately  acute  onset,  bilateral,  with  considerable  im- 
pairment of  hearing,  much  noise  and  fulness,  and  some 
dizziness.  The  impairment  referred  to  air-conduction, 
not  to  bone-conduction.  The  drumhead  was  cloudy  and 
sometimes  slightly  injected.  Eustachian  inflation  showed 
diminished  patency  and  the  presence  of  a  very  scant 
exudate.  Inflation,  however,  did  not  improve  subjec- 
tively or  objectively.  Specific  treatment  likewise  pro- 
duced no  noticeable  benefit  inside  of  two  to  three  weeks. 
Unfortunately,  none  of  the  patients  were  observed  for 
any  great  length  of  time. 


CHAPTER   XXXVI. 

ADHESIVE  OR   PROLIFERATIVE   INFLAMMATION 
OF   THE   MIDDLE   EAR. 

340.  The  names  "adhesive,  proliferative,  plastic,  or 
hypertrophic  "  otitis,  or  "dry  catarrh  "  of  the  middle  ear, 
refer  to  an  aflfection  of  the  middle  ear  which  must  be 
considered  the  analogue  and  extension  of  hypertrophic 
rhinitis.  Very  rare  in  early  childhood,  it  cannot  be 
called  common  until  after  growth  is  finished,  from  which 
time  on  its  frequency  increases  until  every  third  or  cer- 
tainly every  fourth  individual  in  advanced  age  presents 
some  evidence  of  this  disease.  The  disease  is  rarely 
one-sided — mostly  bilateral.  But  quite  often  one  ear 
is  less  affected  than  the  other,  sometimes  so  little  that 
the  patient  calls  his  disease  one-sided.  The  progress  of 
the  disease  is  not  necessarily  parallel  in  the  two  ears. 

In  typical  cases  it  begins  so  gradually  that  its  exact 
date  of  origin  can  often  not  be  stated.  Ringing  in  the 
ear,  perhaps  only  occasional  at  first,  may  be  ignored  for 
a  long  time  until  it  becomes  annoying.  Later  on  it  may 
become  the  main  complaint,  more  serious  to  the  patient 
even  than  the  deafness.  In  neurasthenics  tinnitus  can 
cause  much  sufiering  and  unhappiness.  "  Stuffy  "  sensa- 
tions are  usually  not  present  to  any  distressing  extent 
except  in  complicated  cases.  Dizziness  is  likewise  not 
a  strictly  "normal"  symptom  of  adhesive  otitis,  but  it 
does  occur  in  a  small  proportion  of  cases  on  account  of 
some  special  localization  of  the  lesion  or  as  a  complica- 
tion, and  it  may  prove  very  distressing.  The  hearing 
becomes  affected  gradually.  Sometimes  the  patient  is 
not  conscious  of  any  impairment  for  many  months;  in 
other  cases  he  is  annoyed  from  the  start.  The  impair- 
ment is,  of  course,   most  perceptible  when  listening  to 

442 


ADHESIVE    INFLAMMATION    OF   THE    MIDDLE    EAR.  443 

faint  sounds — for  instance,  in  the  telephone.  The  dis- 
ease never  ends  in  absolute  deafness.  Except  in  case  of 
ankylosis  of  the  stapes,  loud  speech  can  always  be  under- 
stood close  to  the  ear.  It  may  take  years  before  the  per- 
ception of  ordinary  conversation  becomes  embarrassing; 
but  in  those  instances  in  which  ankylosis  between  the 
foot-plate  of  the  stirrup  and  the  oval  window  takes  place, 
the  hearing  is  much  more  seriously  compromised.  This 
is,  on  the  whole,  not  a  frequent  occurrence  in  adhesive 
otitis.  It  may  begin  early  or  late  in  the  course,  and 
when  begun,  it  may  reach  its  completion  within  weeks 
or  within  several  years.  When  complete,  it  practically 
bars  hearing  of  the  voice,  except  through  a  speaking 
tube.  It  is  a  common  observation  in  hypertrophic  otitis 
that  conversation  is  better  understood  in  noisy  surround- 
ings, like  railroad  cars,  etc.,  than  where  silence  prevails. 

Tests  show  that  a  faint  whisper  is  not  heard  normally 
even  at  a  time  when  the  patient  claims  normal  hearing. 
As  a  rule,  the  perception  of  the  watch  is  more  impaired 
in  this  disease  than  that  of  the  voice.  Tuning-fork  tests 
show  air-conduction  diminished,  especially  for  low  tones, 
for  which  bone-conduction  is  normal,  or  later  on  even 
increased.  In  Weber's  test  the  sound  is  localized  in 
the  more  affected  ear,  except  in  cases  complicated  with 
lesions  in  the  internal  ear.  Rinne's  test  shows  impaired 
air-conduction;  later  on  its  normal  formula  becomes  re- 
versed, especially  for  low  tones  (Rinne  negative). 

The  course  of  proliferative  otitis  is  variable.  It  is  only 
a  small  minority  of  cases  that  continue  to  get  worse 
steadily.  This  severe  course  is  favored  by  pronounced 
hypertrophic  rhinitis  with  nasal  stenosis;  but  it  may 
happen,  too,  even  without  nasal  obstruction.  On  the 
other  hand,  a  fair  majority  of  patients  lose  their  noises 
and  feeling  of  stuffiness  and  retain  their  hearing  for  a 
time  without  further  continuous  impairment.  The  dis- 
ease has  apparently  come  to  a  stand-still.  The  damage 
done  to  the  hearing  is  usually  permanent,  as  a  rule,  even 
under  treatment.     This  apparent  arrest  of  the  disease  is 


444        ADHESIVE    INFLAMMATION    OF    THE    MIDDLE    EAR. 

in  most  cases  not  permanent.  With  a  fresh  "cold"  in 
the  nose  the  symptoms  return  to  a  variable  degree. 
Whether  or  not  the  loss  of  hearing  power  is  steadily  pro- 
gressive can  be  judged  only  by  the  history  during  a 
period  of  at  least  some  months.  But  the  presence  of 
other  symptoms,  tinnitus,  fulness,  or  discomfort  of  any 
kind,  is  evidence  of  the  progressive  character  of  the  dis- 
ease. Yet  a  permanent  arrest  of  the  disease  is  not  so  very 
rare.  It  can  be  expected  only  if  the  irritative  symptoms 
are  either  of  recent  origin,  or  if  of  longer  duration,  have 
not  been  continuous.  The  younger  the  patient  when  the 
disease  began,  the  less  probable  is  a  favorable  termination. 

341.  The  clinical  course  of  proliferative  otitis  is  com- 
plicated in  some  instances  by  a  slight  degree  of  exudative 
catarrh.  A  small  number  of  cases  of  exudative  catarrh 
change  gradually  into  the  plastic  form,  and  thenceforth 
present  the  combined  lesions  of  hypertrophy  with  mu- 
cous secretion  into  the  drum  cavity.  Others  do  not  give 
the  history  of  acute  onset,  but  pursue  a  mild,  subacute 
course  from  the  beginning,  with  considerable  variation  in 
the  degree  of  exudative  inflammation  in  consequence  of 
changed  environment  or  as  the  result  of  treatment.  This 
"mixed"  type  of  middle-ear  disease  is  aggravated  by 
every  fresh  "cold"  in  the  nose  more  so  than  the  purely 
proliferative  form  without  secretion.  But,  on  the  other 
hand,  it  is  also  more  readily  influenced  favorably  by  treat- 
ment. In  adhesive  otitis,  but  especially  when  some  exu- 
dation is  present,  the  patients  claim  to  hear  worse  in  bad 
weather.  The  complaint  is  not  always  corroborated  by 
actual  test.  The  patient  is  at  times  deceived  as  to  his 
hearing  power  by  the  subjective  feeling  of  fulness  or  the 
tinnitus  which  may  be  increased  by  unfavorable  weather. 

342.  The  morbid  changes  in  plastic  otitis  consist  of 
inflammatory  swelling,  hypertrophy,  fibrillary  sclerosis, 
and  adhesions  of  the  mucous  membrane.  In  the  pure 
type  of  proliferative  inflammation  the  lesions  are  often 
localized,  especially  around  the  articulation  of  hammer 
and  anvil.     When  exudation  is  present,   the  process  is 


MORBID    CHANGES.  445 

more  likely  to  be  diffuse.  The  exudate,  if  present,  is 
scant  mucus,  sometimes  very  viscid.  Diffuse  inflamma- 
tory swelling  occurs  probably  only  during  subacute  exacer- 
bations, or  in  the  case  of  exudative  catarrh  gradually 
changing  into  a  plastic  otitis.  Ordinarily  more  or  less 
circumscribed  hypertrophy  of  the  lining  is  found,  the 
surface  being  uneven,  sometimes  with  papillary  or  villous 
prominences.  The  articulations  may  be  imbedded  in 
hypertrophied  mucous  membrane.  As  a  result  of  much 
thickening,  the  protruding  prominences  of  the  lining 
come  into  contact  and  form  adhesions,  especially  between 
the  joint  of  hammer  and  anvil  and  the  opposite  walls. 
In  other  instances  the  membrane  is  not  hypertrophied, 
but  transformed  into  relatively  rigid  fibrous  tissue.  It 
has  no  longer  its  normal  delicacy  and  pliancy,  but  binds 
down  the  mobile  parts  which  it  envelops.  Instead  of 
broad  adhesions  of  mucous  membrane,  narrow  rigid  ad- 
ventitious bands  are  found  bridging  from  one  surface  to 
another.  There  is  no  good  reason  to  consider  this  fibril- 
lary sclerosis  as  the  later  transformation  of  hypertrophy 
of  the  mucous  membrane.  It  is  more  likely  the  result 
of  imperfect  involution  of  inflammation  under  unknown 
conditions.  The  mobility  of  the  hammer  is  reduced,  and 
its  normal  position  changed  into  one  of  increased  obli- 
quity, which  is  maintained  partly  by  adhesions,  partly  by 
contraction  of  the  ligaments  and  of  the  tensor  tympani 
muscle.  The  latter  maj^  be  shortened  by  fibrillary  trans- 
formation or  bound  down  by  adhesions.  The  prolifera- 
tive changes  may  extend  to  the  round  window,  thicken- 
ing its  diaphragm.  When  the  disease  attacks  the  vicinity 
of  the  oval  window,  it  leads  to  ankylosis  of  the  foot-plate 
of  the  stirrup,  the  most  serious  lesion  possible  in  the 
middle  ear  so  far  as  sound-conduction  is  concerned.  Even 
a  partial  involvement  of  the  articulation  by  fibrillary 
transformation  of  the  tissues  damages  its  function.  In 
complete  ankylosis  the  foot-plate  is  bound  down  by  rigid 
fibrous  tissue,  sometimes  with  interstitial  deposition  of 
lime-salts.     Bony  ankylosis  does  not  often  take  place  in 


44^        ADHESIVE    INFLAMMATION    OF    THE    MIDDLE    EAR. 

proliferative  otitis  ;  more  so,  however,  in  disease  of  the 
bony  capsule  of  the  vestibule  (see  f  350). 

The  Eustachian  tube  is  involved  in  this  disease,  at 
least  at  its  tympanic  end.  In  all  probability  the  Eusta- 
chian lesion  is  the  primary  one  in  plastic  otitis.  Morbid 
changes  are  found,  as  a  rule,  in  the  bony  (tympanic)  por- 
tion of  the  canal,  while  the  cartilaginous  part  of  the  tube 
internal  to  the  isthmus  is  mostly  normal.  The  lesions 
correspond  to  those  in  the  middle  ear — viz.,  diflfuse  thick- 
ening of  the  mucous  lining,  or  fibrillary  sclerosis  with 
concentric  narrowing,  sometimes  adhesions,  often  valve- 
like overlapping  of  the  tympanic  opening  by  a  fold  of 
mucous  membrane.  Circumscribed  cicatricial  strictures 
like  those  found  in  the  urethra  do  not  seem  to  occur  in 
the  tube.  The  pharyngeal  portion  of  the  Eustachian 
lining  shows  more  or  less  inflammatory'  swelling  (leuko- 
cytic infiltration)  or  permanent  hypertrophy,  according 
to  the  character  of  the  primary  nasopharyngeal  lesions. 

343.  Etiology. — Proliferative  otitis  is  the  extension  of 
chronic  nasal  inflammation  into  the  middle  ear.  It  is 
never  obser\'ed  when  seen  at  the  start,  except  in  connec- 
tion with  chronic  nasal  disease.  If  the  latter  heals  as  the 
result  of  changed  environment  or  treatment,  the  lesions 
of  adhesive  otitis  may  persist  in  the  ear — apparently  inde- 
pendently ;  but  the  loss  of  hearing  is,  as  a  rule,  not  pro- 
gressive. The  nasal  etiology  is  illustrated  strikingly  by 
the  coincidence  of  the  first  or  more  affected  ear  with  the 
narrower  side  of  the  nose  in  the  case  of  one-sided  sten- 
osis. There  are,  however,  some  rare  exceptions  to  this 
rule.  Fluctuations  in  the  degree  of  nasal  inflammation 
are  usually  accompanied  by  similar  variations  of  the 
condition  of  the  ear,  especially  when  we  review  longer 
periods  in  the  patient's  history.  The  dependence  of  the 
ear  disease  upon  chronic  rhinitis  is  demonstrable  in  some 
instances  by  the  arrest  of  the  former  by  nasal  treatment. 
There  are,  however,  various  reasons  why  this  therapeutic 
test  is  not  always  successful.  Nasal  treatment,  even 
operative,  however  successful  it  may  be,  does  not,  as  a 


DIAGNOSIS.  447 

rule,  eradicate  all  chronic  inflammation  of  the  nasal 
mucous  membrane.  It  only  removes  the  annoyance 
caused  by  the  rhinitis,  but  the  diseased  membrane  still 
remains  in  a  state  of  slight  chronic  inflammation.  More- 
over, an  actual  hypertrophy  of  mucous  membrane  once 
produced  is  a  permanent  lesion.  It  is  only  the  inflamma- 
tory swelling  which  is  transient  ;  the  thickening  of  the 
mucous  membrane  not  due  to  round-cell  infiltration,  but 
to  real  hyperplasia  does  not  disappear  spontaneously 
or  in  consequence  of  treatment.  It  can  hence  not  be 
expected  that  any  changes  in  the  middle  ear  beyond 
those  of  inflammatory  swelling  should  disappear,  even 
after  the  influences  which  brought  them  on  have  ceased. 
Besides,  when  permanent  changes  in  the  Eustachian 
tube  have  reduced  its  patency,  either  by  relative  stenosis 
or  by  rigidity  of  its  mobile  portion,  the  deleterious  con- 
sequences of  reduced  intratympanic  air-pressure  persist 
even  though  the  nasal  lining  were  again  made  normal. 
If,  at  the  same  time,  the  tympanic  mucous  membrane 
has  begun  shrinking  by  fibrous  transformation,  further 
reduction  of  the  mobility  of  the  ossicles  and  fixation  in 
a  faulty  position  are  inevitable. 

While  a  simple  chronic  rhinitis  without  coarse  struc- 
tural changes  or  stenosis  is  sufficient  to  start  plastic  otitis 
media,  the  course  of  the  latter  is  apt  to  be  hastened  and 
intensified  by  nasal  stenosis  or  circumscribed  hyper- 
trophies. This  view,  suggested  by  the  observation  of 
any  large  series  of  patients  with  a  variety  of  nasal  lesions, 
is  often  confirmed  by  the  beneficial  results  of  nasal  opera- 
tions when  done  at  an  early  stage  of  the  ear  disease. 

344.  The  diagnosis  of  proliferative  otitis  is  based — (a) 
on  the  results  of  the  functional  tests  showing  reduced 
air-conduction,  with  normal  or  exaggerated  bone-con- 
duction; (d)  on  the'  appearances  of  the  drumhead;  and 
(c)  on  the  evidence  furnished  by  inflation.  The  mem- 
brana  tympani,  normal  at  first,  gets  dull  and  opaque  in 
most  instances.  Its  luster  becomes  dimmed.  Chalky 
white    spots    of    calcification   are    not    rare,    but    these 


448 


ADHESIVE    INFLAMMATION    OF    THE    MIDDLE    EAR. 


changes  in  the  membrane,  although  indicative  of  plas- 
tic inflammation,  do  not  permit  any  conclusions  as  to 
the  hearing  or  the  progress  of  the  disease  (Figs.  127- 
129  ;  compare  also  Fig.  4,  Plate  II.).  They  may  co- 
incide with  normal  hearing  and  arrested  disease,  while, 
on  the  other  hand,  in  an  unfavorable  case  the  drum- 
head is  sometimes  not   altered   structurally  at  all.      In 


Fig.  127. — Pronounced  retraction  of  drumhead  in  chronic  hypertrophic 
middle-ear  catarrh  with  Eustachian  stenosis.  The  membrane  has  nearly  its 
nonnal  luster,  but  is  discolored  and  less  translucent  than  normally.  Instead  of 
the  normal  triangular  spot  there  is  a  crescentic  reflex  figure. 

subacute  exacerbation  there  may  be  a  vascular  streak 
parallel  to  the  hammer,  but  ordinarily  the  membrane  is 
pale.  Of  decisive  importance  is  the  change  in  the  shape 
of  the  membrane.  Retraction  of  the  drumhead  with 
obliquity  of  the  handle  of  the  hammer  characterizes 
the  majority  of  instances.     It  is  indicative  of  impaired 


Fig.  128. — Drumhead  cloudy,  dis- 
colored (thickened),  and  moderately 
retracted  in  long-standing  chronic 
proliferative  middle-ear  disease. 


Fig.  129. — Cloudy  and  thick- 
ened membrana  tympani  with  sjxjts 
of  calcification  in  chronic  prolifer- 
ative catarrh  of  the  middle  ear. 


Eustachian  patency,  which  is  always  incident  to  the 
course  of  the  disease.  There  are  exceptional  cases  in 
which  the  Eustachian  patency  is  not  demonstrably 
diminished  in  the  earlier  period,  and  the  drumhead 
may  then  have  its  normal  position.  But  if  the  tube  is 
found  normal  after  a  history  of  active  disease  for  months, 


DIAGNOSIS.  449 

this  fact  would  change  the  diagnosis  for  that  of  "scle- 
rosis. ' ' 

Inflation  by  Valsalva  or  Politzer  shows  diminished 
patency  of  the  Eustachian  tube  in  this  disease,  when 
it  affects  the  two  ears  unequally.  When  symmetric  on 
both  sides,  the  obstruction  is  not  noticeable  in  this  man- 
ner until  quite  pronounced.  The  catheter,  too,  gives  a 
sound,  usually  from  the  very  beginning,  indicating  nar- 
rowed caliber,  of  course,  most  appreciable  on  comparing 
two  sides  not  equally  affected.  The  Eustachian  ob- 
struction is  never  sufficient  to  prevent  inflation  by  the 
catheter,  but  it  may  finally  make  the  Politzer  method 
inefficient.  The  diagnosis  of  slight  secretion  as  a  com- 
plication must  be  based  entirely  on  the  auscultation  sound 
on  inflating,  as  there  is  no  other  evidence  of  it. 

The  effect  of  inflation  varies  according  to  the  pre- 
dominance of  Eustachian  obstruction  or  of  plastic  changes 
in  the  drum.  The  latter  are  not  influenced,  while  the 
mechanical  disturbances  of  tubal  closure  are  temporarily 
relieved.  There  may  thus  be  a  fair  subjective  improve- 
ment of  more  or  less  duration,  but  never  so  striking  as 
in  exudative  catarrh.  On  the  other  hand,  inflation  may 
have  no  effect  whatsoever.  The  result  of  the  first  inflation 
determines  the  prognosis.  The  greater  the  subjective  im- 
provement, the  more  reason  to  assume  that  the  changes 
in  the  tube  and  drum  are  still  capable  of  resolution.  The 
prognosis,  however,  depends  even  more  on  the  duration 
of  the  benefits  of  Eustachian  inflation  than  on  their  im- 
mediate degree. 

Inflation  does  not  always  clear  the  ears  at  once:  some 
patients  feel  the  subjective  improvement  only  after  the 
lapse  of  some  hours.  The  immediate  results  of  infla- 
tions cannot  be  gauged  merely  by  the  improvement  in 
the  hearing.  This  is  never  so  marked  as  in  exudative 
catarrh ;  indeed,  mostly  not  very  striking  at  all,  often  not 
measurable  objectively.  But  the  effect  on  the  tinnitus 
and  on  any  fulness  felt  in  the  ear  is  the  test  of  its  bene- 
ficial influence.     When  thorough    inflation  through  the 

29 


450         ADHESIVE    INFLAMMATION    OF   THE    MIDDLE    EAR. 

catheter  gives  no  subjective  relief,  either  at  once  or  in 
the  course  of  some  hours,  there  is  nothing  to  be  gained 
by  its  repetition. 

345.  For  the  purpose  of  treatment  inflation  should  be 
practised  daily  as  long  as  it  influences  the  hearing  or  the 
discomfort  of  the  patient.  Longer  intervals  in  the  treat- 
ment mean  a  waste  of  time.  As  soon  as  inflation  fails 
to  improve  the  condition  for  at  least  a  few  hours,  it  is 
useless  to  continue  it.  Sometimes  its  period  of  useful- 
ness is  over  after  a  few  weeks  of  treatment;  in  other  in- 
stances it  is  of  some  benefit  in  staying  the  disease  during 
months.  The  fluctuations  of  proliferative  otitis  may 
demand  a  repetition  of  inflation  when  the  disease  gets  a 
fresh  start.  While  it  will  generally  be  found  that  cathe- 
terization is  more  effective  than  the  Politzer  inflation,  yet 
the  latter  may  be  left  to  the  patient  as  an  additional  help. 
Many  persons  can  learn  to  catheterize  themselves,  if  re- 
quired. The  final  results  of  a  course  of  inflation  are  very 
variable,  depending  largely  on  the  transient  or  permanent 
character  of  the  constricting  lesion  in  the  Eustachian 
tube,  and  of  the  changes  in  the  drum  cavity.  They  can 
be  predicted  with  moderate  certainty  from  the  effect  (and 
especially  its  duration)  after  the  first  inflation.  The 
utility  of  vapors — turpentine,  iodin,  chloroform,  or  finely 
divided  powders  (freshly  formed  chlorid  of  ammonium) 
— injected  through  the  catheter  has  been  discussed  in 
1  338.  As  a  rule,  critical  comparison  does  not  show  any 
pronounced  advantage  over  simple  inflation,  and  even  in 
the  apparently  favorable  instances  a  true  appreciation  of 
the  value  of  these  agents  is  very  difficult.  Dilatation  of 
the  Eustachian  tube  by  sounds  introduced  tlirough  the 
catheter  has  not  been  found  useful  by  many  observers, 
although  recommended  by  some.  It  is  painful  to  reach 
the  osseous  portion,  which  is  usually  the  part  involved. 
Moreover,  there  is  no  reason  to  expect  a  permanent 
benefit  from  the  transient  pressure  by  the  probe. ^ 

^  Recently  electrolysis  of  the  Eustachian  tube  hns  been  highly  indorsed  for 
the  cure  of  inflammatory  narrowing  (Duel,  Kenefick).     Through  a  well-fitting 


TREATMENT.  45 1 

Pneumomassage  (1  306)  of  the  drumhead  and  ossicles 
is,  as  a  rule,  subjectivel)'  agreeable.  Its  long  continu- 
ance, about  one  to  two  minutes,  twice  daily,  is  often  of 
some  little  influence  upon  the  hearing  and  the  noises. 
Yet  its  value  is  enormously  overrated  in  some  reports. 
If  a  few  tests  do  not  show  very  decided  benefit,  it  is  more 
appropriate  to  let  the  patient  keep  up  the  exercise  at 
home  for  months  than  to  force  him  to  come  to  the  sur- 
geon's office. 

How  much  benefit  may  be  expected  from  nasal  treat- 
ment in  hypertrophic  otitis  can  be  inferred  from  the 
etiologic  discussion  in  1  343.  In  instances  of  relatively 
short  duration, — months, — and  especially  in  those  charac- 
terized by  rapid  course  and  fluctuations  in  the  severity  of 
the  aural  symptoms,  a  decided  improvement  will  often 
follow  the  successful  operation  of  nasal  lesions.  Re- 
moval of  septum  deformities,  snaring  of  hypertrophies 
of  the  inferior  turbinal,  cauterization  of  excessive  cavern- 
ous tissue,  either  anterior  or  posterior,  and  especially 
galvanocaustic  destruction  of  vascular  prominences  at 
the  rear  of  the  septum  (1  94  and  %  97)  give  at  times  very 
satisfactory  results,  both  as  regards  improvement  of  hear- 
ing and  disappearance  of  tinnitus  and  fulness.  But  such 
fortunate  instances  constitute  only  a  small  minority  and 

Eustachian  metal  catheter  insulated  on  its  external  surface  by  means  of  rubber 
an  olive-tipped  gold  wire,  i  mm.  wide  at  its  bulbous  end,  is  pushed  into  the 
tube  until  it  enters  nearly  or  quite  up  to  the  middle  ear  (about  35  mm.  beyond 
the  end  of  the  catheter).  As  soon  as  resistance  is  encountered,  the  gold  wire 
is  made  the  negative  pole  of  a  battery  current  of  ^  to  not  over  4  milliamp^res  m 
strength.  The  positive  pole  may  be  a  sponge  or  a  bowl  of  salt  water  into 
which  the  patient  dips  his  hand  gradually  in  order  to  avoid  a  shock.  This  cur- 
rent is  employed  for  a  few  minutes.  During  its  action  the  probe  glides  easier 
through  the  narrowed  Eustachian  passage  than  previously.  Inflation  must  not 
be  practised  for  at  least  a  day  for  fear  of  causing  emphysema.  It  has  been 
claimed  that  in  many  instances  decided  relief  from  the  tinnitus  and  fulness  fol- 
lows the  first  application,  and  the  hearing  may  improve  correspondingly.  A 
few  repetitions  in  intervals  of  some  weeks  are  said  to  have  given  permanent 
results  in  many  instances.  The  method  has  not  yet  been  tried  sufficiently  by 
others  to  test  its  value.  Personal  trial  has  shown  me  that  in  spite  of  care  and 
antiseptic  precautions  a  mild  grade  of  suppurative  otitis  may  be  caused  by  it. 


452         ADHESIVE    INFLAMMATION    OF    THE    MIDDLE    EAR. 

cannot  be  foretold  with  certainty.  Of  most  cases,  how- 
ever, it  can  be  said  that  nasal  treatment  will  tend  to 
arrest  the  ear  disease  in  proportion  to  its  result  upon 
the  nasal  disease.  It  must  again  be  emphasized  that 
in  hypertrophic  rhinitis  operations  which  relieve  the  pa- 
tient subjectively  do  not  necessarily  restore  the  normal 
state  of  the  nasal  mucous  membrane,  and  that,  indeed, 
our  therapeutic  control  over  this  disease  is  limited.  But, 
on  the  whole,  all  measures  benefiting  the  nasal  affection 
give  the  ear  the  best  chances  possible  for  the  arrest  of  the 
disease.  This  applies  not  only  to  operations  and  medi- 
cinal treatment,  but  equally  to  all  hygienic  measures 
referred  to  in  T[  14  to  ^  17.  But  in  spite  of  all  care,  the 
prognosis  is  doubtful  in  many  instances,  even  at  the 
beginning,  and  bad  in  most  advanced  cases.  The  his- 
tory of  steadily  progressive  deafness  with  tinnitus  not 
controllable  by  inflation,  the  demonstration  of  Eustachian 
stenosis,  and  the  absence  of  gross  lesions  in  the  nose  give 
the  therapeutist  little  chance  for  successful  intervention. 


CHAPTER   XXXVII. 

OPERATIONS   FOR  THE  RELIEF  OF   DEAFNESS  DUE 
TO  ADHESIVE  PROCESSES  IN  THE  MIDDLE  EAR, 

346.  The  uncertainty  of  treatment  in  hypertrophic 
disease  of  the  middle  ear  has  led  to  various  operative 
attempts. 

A  striking  observation  is  the  exemption  of  those  ears 
from  any  form  of  progressive  deafness  in  which  there  is 
a  permanent  perforation  of  the  drumhead.  When  this 
is  one-sided,  the  ear  does  not  even  participate  if  the 
other  ear  with  intact  drumhead  becomes  gradually  deaf 
from  plastic  inflammation.  In  view  of  the  frequency  of 
hypertrophic  middle-ear  disease  this  exemption  is  quite 
remarkable.  As  long  as  a  middle  ear  with  perforated 
drumhead  still  continues  to  suppurate  the  hearing  is 
occasionally  further  damaged  by  subacute  exacerbations. 
But  after  the  suppuration  has  ceased,  the  hearing  of  such 
an  ear  remains  stationary.  It  is  self-evident  that  a  per- 
foration in  the  drumhead  prevents  all  the  pernicious  con- 
sequences of  Eustachian  obstruction.  Observations  on 
ears  with  healed  suppuration  but  persisting  defect  in  the 
membrane  suggest,  moreover,  that  even  those  intratym- 
panic  changes  which  so  often  occur  in  connection  with 
but  moderate  impairment  of  the  Eustachian  patency  are 
secondary  to  the  latter.  It  would  hence  be  a  perfectly 
justifiable  operation  to  make  a  permanent  fistula  in  the 
drumhead  in  all  cases  of  beginning  middle-ear  catarrh, 
if  we  only  knew  of  any  method  to  maintain  a  perma- 
nent perforation.  It  sounds  paradox  that  we  cannot 
imitate  nature  in  the  example  she  sets  in  every  chronic 
purulent  otitis.  In  the  latter  case  the  edges  of  the  per- 
foration are  cicatrized  and  covered  with  epithelium,  and 

453 


454    RELIEF    OF    DEAFNESS    DUE   TO    ADHESIVE    PROCESSES. 

the  hole  is  permanent  and  can  be  closed  only  artificially. 
On  the  other  hand,  every  attempt  to  maintain  a  perma- 
nent perforation  by  exsecting  a  piece  of  or  even  the 
whole  drumhead  or  by  inserting  a  cufi"-button-shaped 
cannula  or  clamping  a  U-shaped  perforated  tube  around 
the  manubrium  mallei  has  proved  a  failure.  When  the 
tendinous  insertion  of  the  membrane  in  its  bony  frame 
is  chiseled  away,  regeneration  is  often,  but  even  then  not 
always  prevented.  The  preventive  operative  treatment 
of  chronic  middle-ear  catarrh  is  hence  a  matter  of  the 
future.  There  is  no  good  reason,  however,  to  believe 
that  a  permanent  perforation  would  necessarily  prevent 
the  continuance  of  adhesive  and  ankylotic  processes  in 
the  middle  ear  after  they  have  been  well  started.  In 
advanced  cases  of  middle- ear  catarrh  some  temporary 
relief  is  sometimes,  but  not  always,  obtained  by  punctur- 
ing the  drumhead. 

A  different  procedure  was  suggested  by  observations  in 
chronic  purulent  otitis  rebellious  to  conservative  treat- 
ment. It  has  been  found  that  the  removal  of  the  ossicles, 
together  with  the  drumhead,  does  not  often  damage  the 
impaired  hearing,  but,  on  the  contrary,  is  quite  apt  to 
improve  it,  sometimes  to  a  striking  extent.  In  favorable 
instances  ordinary  conversation  can  be  well  heard  in  the 
absence  of  the  drumhead,  the  hammer,  and  the  anvil, 
although,  of  course,  the  hearing  is  far  from  being  perfect. 
Attempts  have,  therefore,  been  made  by  many  surgeons 
to  remove  these  parts  in  progressive  deafness  due  to 
plastic  processes  without  suppuration.  The  operation, 
moderately  painful,  can  be  tolerated  without  general  nar- 
cosis only  by  a  courageous  individual.  Cocain  is  of  ser- 
vice only  after  the  drumhead  has  been  opened,  not  before. 
Suprarenal  solution  is  of  considerable  help  in  suppress- 
ing troublesome  hemorrhage.  The  operation  through 
the  meatus  is  feasible  only  when  the  latter  is  normally 
wide.  Otherwise  preliminary  detachment  of  the  cartila- 
ginous meatus  would  be  necessary  (1  327).  The  most 
advantageous  illumination  is  that  by  an  electric  lamp  on 


OPERATIONS.  455 

the  forehead.  The  drumhead  is  detached  from  its  inser- 
tion by  a  curved  peripheral  anterior  and  a  similar  pos- 
terior incision  from  above  downward.  A  fine  bent  knife 
then  severs  the  tensor  tympani  tendon  and  the  joint 
between  the  long  processes  of  the  anvil  and  the  head  of 
the  stapes.  A  delicate  snare  is  pushed  up  until  it  grasps 
the  head  of  the  hammer,  and  with  cautious  prying  move- 
ments the  latter  is  taken  out.  If  the  anvil  does  not 
follow,  it  may  then  be  searched  for  with  the  snare,  or 
with  small,  variously  bent  hooks.  The  removal  of  the 
anvil  is  not  easy,  and  sometimes  impossible.  Under 
absolute  asepsis  and  the  avoidance  of  syringing  there  is 
very  little  reaction  and  no  suppuration.  The  after-treat- 
ment consists  only  in  placing  a  sterile  gauze  tampon  into 
the  meatus.  With  thorough  knowledge  of  the  anatomy 
the  only  accident  to  be  feared — and  that  not  a  common 
one — is  injury  to  the  stapes.  In  the  latter  case  severe 
dizziness  may  ensue  for  days.  Severe  purulent  otitis 
may  occur  in  case  of  imperfect  asepsis.  Through  care- 
lessness the  facial  nerve  may  be  wounded. 

347-  There  is  no  doubt  that  the  operation  has  in- 
fluenced the  hearing  favorably  in  a  small  proportion  of 
cases.  In  a  larger  number  of  instances  the  distressing 
noises  have  been  permanently  benefited.  It  cannot  be 
learned  with  certainty  from  published  reports  whether 
the  hearing  remained  stationary  in  any  large  number  of 
instances  after  this  operation.  Very  few  cases  seem  to 
have  been  watched  for  a  sufficiently  long  time.  On  the 
other  hand,  in  a  minority  of  instances  the  tinnitus  was  not 
benefited,  and  in  a  large  majority  no  gain  accrued  to  the 
hearing  power,  while  not  rarely  the  latter  was  seriously 
damaged.  The  operation  has  been  abandoned  by  many 
former  enthusiasts  ;  still,  it  does  not  deserve  to  be  unre- 
servedly condemned,  but  it  should  be  understood  that  its 
prognosis  is  absolutely  uncertain.  In  a  number  of  in- 
stances the  moderate  benefit  temporarily  obtained  was 
lost  after  the  membrane  became  regenerated. 

348.  Tenotomy  of  the  tensor  tympani  muscle  has  been 


4S6    RELIEF    OF    DEAFNESS    DUE   TO    ADHESIVE   PROCESSES. 

practised  considerably  in  former  years,  sometimes  with 
some  temporary  benefit,  but  has  now  been  abandoned  as 
inefficient. 

The  removal  of  the  ankylosed  stapes  has  been  done 
quite  a  number  of  times,  especially  by  Blake  and  Jack. 
The  hammer  and  anvil  need  not  necessarily  be  removed 
in  this  operation,  but,  of  course,  the  drumhead  must  be 
partially  detached.  As  a  rule,  there  is  severe  reaction  in 
the  form  of  dizziness,  if  the  foot-plate  of  the  stirrup  is 
really  removed  by  the  operation.  Although  some  benefit 
has  been  claimed,  this  delicate  operation  has  not  gained 
favor  among  otologists. 

In  relatively  rare  instances  an  adhesion  of  the  drum- 
head or  even  of  the  manubrium  to  the  internal  tympanic 
wall  results  from  a  destructive  purulent  otitis.  In  such 
cases  a  moderate  benefit  to  the  hearing,  but  especially  a 
relief  of  tinnitus,  may  be  obtained  by  dividing  the  adhe- 
sions with  a  minute  knife  bent  on  the  flat. 

349.  Abnormal  relaxation,  with  flaccidity  of  the  mem- 
brana  tympani,  is  sometimes  met  with  from  unknown 
causes,  perhaps  at  times  from  imprudent  repetitions  of 
Valsalva  inflation  by  the  patient.  Occasionally,  too, 
large  cicatrices  of  the  drumhead  are  seen  to  be  flaccid 
and  possess  abnormal  mobility  when  tested  with  the 
Siegle  pneumatic  speculum.  This  condition  reduces  the 
hearing  without  other  symptoms.  In  such  rare  instances 
an  improvement  in  the  hearing  can  be  obtained  by  render- 
ing the  drumhead  more  tense  by  a  coating  of  collodion. 
Whenever  the  condition  returns  by  reason  of  the  collo- 
dion peeling  off,  the  membrana  tympani  may  be  brushed 
again  with  the  solution. 


CHAPTER   XXXVIII. 

'♦SCLEROSIS  OF  THE  MIDDLE  EAR"  (RAREFACTION 

OF  THE   CAPSULE   OF  THE   LABYRINTH) 

ANKYLOSIS   OF  THE   STAPES. 

350.  It  had  been  noticed  by  even  the  earlier  otologists 
that  there  is  a  certain  type  of  progressive  deafness  which, 
while  it  resembles  "dry  catarrh"  of  the  middle  ear, 
differs  from  it  sufficiently  to  be  distinguishable  clinically. 
On  account  of  false  pathologic  ideas  this  disease  has  been 
termed  sclerosis  of  the  middle  ear.  Its  true  pathology 
has  now  been  so  completely  demonstrated  (by  Politzer, 
Siebenman,  and  others)  that  an  accurate  differentiation 
is  possible.  Although  an  affection  of  the  sound-conduct- 
ing parts,  it  is  really  not  a  disease  of  the  mucous  mem- 
brane of  the  middle  ear. 

The  disease  begins  usually  between  the  fifteenth  and 
twentieth  years  of  life,  less  often  later  on,  predominantly 
in  females.  It  occurs  in  rather  less  than  5  per  cent,  of 
ear  patients.  It  is  always  double-sided,  and,  as  a  rule, 
without  much  difference  between  the  two  ears.  A 
hereditary  tendency  to  ear  disease  is  often  found  in  the 
family.  The  hearing  becomes  gradually  dulled,  with 
very  little  other  annoyance.  No  fulness,  no  stuffiness, 
no  dizziness.  Tinnitus  is  sometimes  complained  of  to  a 
moderate  extent  ;  it  is  neither  constant  nor  steady.  In 
the  course  of  some  years  it  becomes  difficult  to  follow  a 
conversation.  In  some  the  deafness  does  not  proceed 
beyond  considerable  embarrassment  in  ordinary  speech. 
In  others  it  is  steadily  progressive,  and  after  many  years 
practically  bars  the  patient  from  social  intercourse. 

These  patients  have  no  catarrhal  history.  During  their 
younger  years  they  are  conspicuously  free  from  nasal  and 
pharyngeal  disturbances,  and  their  rare  attacks  of  coryza 

457 


458  "SCLEROSIS    OF   THE    MIDDLE    EAR," 

heal  promptly.  Later  in  life  slight  chronic  changes  may 
occur  in  the  upper  respiratory  passages  in  unfavorable 
climates.  The  drumhead  is  normal  at  first.  It  may 
become  slightly  retracted,  but  not  necessarily  so.  It 
often  looks  atrophic  by  reason  of  the  special  prominence 
of  the  neck  of  the  hammer.  The  luster  is  normal.  A 
pinkish  hue  due  to  congestion  of  the  promontory  is  often 
noticeable  through  the  translucent  membrane,  and  is  of 
inauspicious  significance.  The  Eustachian  tube  is  normal. 
Functional  tests  show  reduced  air-conduction,  the  result 
of  fixation  of  the  foot-plate  of  the  stapes.  Rinne's  test 
soon  becomes  negative.  The  tuning-fork  on  the  vertex 
is  heard  abnormally  long.  The  main  distinction  between 
this  form  of  disease  and  proliferative  middle-ear  disease 
is  the  pronounced  deafness  for  the  lowest  tones  of  the 
scale  when  heard  through  the  air.  The  range  of  audition 
is  shortened  by  one  to  even  three  octaves  at  the  lower 
end.  In  the  course  of  years  these  tests  become  less  deci- 
sive as  the  disease  is  likely  to  become  complicated  by 
involvement  of  the  auditory  nerve-ends.  This  is  then 
indicated  by  shortening  of  the  upper  end  of  the  auditory 
range  on  testing  with  the  Galton  whistle. 

Sooner  or  later  the  disease  ends  in  complete  ankylosis 
of  the  stirrup — bony  union  of  the  foot-plate  of  the  stapes 
to  the  walls  of  the  niche  in  which  the  oval  window  is 
located.  It  is  not  yet  certain  whether  this  condition  can 
be  invariably  recognized  by  means  of  Gelle's  test  (1  309). 
When  the  bony  ankylosis  is  complete,  the  deafness 
usually  ceases  to  increase.  In  some  instances,  however, 
the  hearing  continues  to  suffer  even  beyond  this  period, 
and  the  functional  tests  then  indicate  involvement  of  the 
nerve-ends  in  the  labyrinth. 

351.  It  was  formerly  supposed  that  this  type  of  disease 
was  due  to  fibrillary  degeneration  of  the  tympanic  mucous 
membrane — hence  the  name,  sclerosis.  This  supposition 
was  entirely  wrong.  The  tympanic  mucous  membrane 
is  normal  in  this  disease.  The  real  lesion  is  disseminated 
rarefaction  of  the  bony  wall  of  the  labyrinth.     Separate 


ANKYLOSIS    OF    THE    STAPES.  459 

small  yellowish  foci  are  found,  especially  in  the  neighbor- 
hood of  the  oval  window.  In  these  spots  the  compact 
bony  substance  is  changed  into  the  cancellated  type. 
The  rarefaction  is  indicated  by  the  presence  of  lacunae 
and  of  osteoclasts.  Enlarged  and  newly  formed  vessels 
render  these  foci  abnormally  vascular.  Later  on  minute 
osteophytes  form  both  on  the  tympanic  and  on  the  intra- 
labyrinthine  surfaces.  This  secondary  proliferative  proc- 
ess culminates  in  bony  ankylosis  of  the  foot-plate  of  the 
stirrup.  It  is  doubtful  whether  the  process  can  be  called 
inflammatory.  It  is  a  return  to  the  embryonic  condition 
of  the  bone  from  unknown  causes.  We  know  nothing 
of  the  etiology  beyond  the  frequent  family  predisposi- 
tion. 

So-called  sclerosis  cannot  be  influenced  therapeutically 
by  any  known  means.  Eustachian  inflation  is  sometimes 
agreeable  subjectively,  but  has  no  permanent  influence 
and  is  even  accused  of  being  harmful  in  the  end.  The 
same  may  be  said  of  massage.  Excision  of  the  ossicles 
or  operative  manipulation  of  the  stapes  only  can  be  con- 
demned on  the  basis  of  experience.  No  internal  medica- 
tion tried  up  to  the  present  time — iodids,  thyroid  gland, 
phosphorus — has  given  any  decisive  results.  It  is  gen- 
erally believed,  perhaps  on  doubtful  evidence,  that  the 
disease  is  least  likely  to  progress  rapidly  when  the 
health   is  maintained  at  par. 

352.  Ankylosis  of  the  stapes  is  a  not  infrequent 
lesion  in  proliferative  middle-ear  catarrh,  as  well  as  in  so- 
called  sclerosis,  in  which  it  is  a  constant  terminal  feature. 
In  the  former  disease  it  is  usually  not  a  bony  union. 
There  may  be  true  sclerosis  of  the  deeper  periosteal  layer 
of  the  mucous  membrane,  causing  fibrous  rigidity,  and 
this  may  be  complicated  by  more  or  less  calcification  or 
even  partial  ossification.  The  lesion  necessarily  causes 
a  high  degree  of  deafness.  It  is  indicated  by  the  rever- 
sion of  Rinne's  test,  by  exaggerated  bone-conduction  and 
total  deafness  for  aerial  sound-waves  of  low  frequency. 
When  in  Gelle's  test  increased  air-pressure  in  the  meatus 


460  ANKYLOSIS    OF   THE    STAPES. 

does  not  reduce  the  perception  of  aerial  sound-waves,  the 
diagnosis  may  be  considered  assured. 

In  most  instances  of  stapes  ankylosis  due  to  prolifera- 
tive catarrh  of  the  middle  ear  the  diagnosis  of  the  catar- 
rhal origin  can  be  easily  made.  There  are  exceptional 
instances  in  which  the  functional  tests  indicate  stapes 
rigidity  at  a  very  early  period,  while  the  other  symptoms 
do  not  as  yet  point  to  any  extensive  proliferative  changes 
in  the  middle  ear.  Such  cases  are  sometimes  difficult  to 
distinguish  from  so-called  sclerosis.  The  latter,  however, 
is  always  bilateral,  while  in  the  former  type  of  disease  it 
is  not  uncommon  to  find  one-sided  instances  with  very 
little  involvement  of  the  other  ear. 

Ankylosis  of  the  stapes  may  also  be  the  consequence  of 
a  purulent  otitis.  If  the  latter  has  healed  without  leav- 
ing visible  evidences  in  the  membrana  tympani,  as  some- 
times happens  in  childhood,  the  diagnosis  of  the  origin 
of  the  ankylosis  may  prove  puzzling. 


CHAPTER   XXXIX. 

SIMPLE   OTITIS    MEDIA    (PURULENT   OTITIS   MEDIA 
WITHOUT    PERFORATION). 

353*  Suppurative  inflammation  of  the  middle  ear  is 
distinguished  from  catarrh  by  the  greater  depth  of  the 
inflammatory  infiltration,  which  may  even  extend  into 
the  bone,  and  by  the  nature  of  the  exudation.  The  lat- 
ter varies  from  clear  serum  to  pure  pus,  but  is  not  the 
more  or  less  turbid  mucus  of  catarrh.  Purulent  otitis 
has  hitherto  been  identified  with  a  clinical  picture  begin- 
ning with  well-defined  pain  and  leading  to  a  perforation 
in  the  drumhead,  with  subsequent  discharge  through  it. 
But  while  this  is  the  predominating  type  of  the  disease, 
there  are  other  forms  which  have  as  yet  received  less 
attention. 

It  has  been  shown  that  a  purulent  inflammation  of  the 
middle  ear  is  found  at  autopsies  in  about  four-fifths  of 
all  dead  nurslings.  There  is  in  this  case  the  same  dis- 
crepancy between  the  frequency  of  the  lesions  found  in 
the  dead-room  and  the  scantiness  of  clinical  observation 
which  has  been  noticed  in  diseases  of  the  nasal  accessory 
cavities.  Kutscharianz,  Kossel,  Ponfick,  and  others  have 
shown  this  remarkable  liability  to  purulent  otitis  in  in- 
fants during  their  last  days  of  life,  apparently  independent 
of  the  cause  of  death.  The  exudate  has  been  found  to 
contain  the  familiar  pyogenic  microbes,  streptococci, 
staphylococci,  and  pneumococci,  as  well  as  in  some 
instances  the  influenza  bacillus.  While  all  evidence 
points  to  invasion  through  the  Eustachian  tube,  which 
at  this  age  is  relatively  wide  and  short,  the  nose  and 
pharynx  were  found  normal  in  many  instances. 

In  nurslings  dying  vshortly  after  birth  Aschoff"  found 
frequently  lanugo  hairs  and  vernix  caseosa  in  the  drum 

461 


462  SIMPLE   OTITIS    MEDIA. 

cavity,  presumably  through  the  entrance  of  amniotic 
fluid  into  the  Eustachian  tube  during  swallowing  move- 
ments of  the  fetus.  On  the  basis  of  this  observation  he 
considers  at  least  some  of  the  instances  of  infantile  otitis 
as  an  inflammatory  reaction,  due  to  the  presence  of  for- 
eigfu  bodies  in  the  middle  ear. 

This  otitis,  complicating  so  many  of  the  diseases  of 
early  infancy,  is  clinically  latent  when  the  child  is  very 
sick  and  apathetic.  In  other  instances  it  is  suggested  by 
restlessness  and  tossing  of  the  head.  A  sudden  rise  of 
temperature  may  be  due  to  it,  as  it  has  been  shown  that 
puncture  of  the  drumhead  may  lower  the  fever  during 
the  course  of  other  ailments  complicated  by  concomitant 
otitis.  It  has  also  been  pointed  out  (Ponfick-Barth)  that 
this  purulent  otitis  with  escape  of  pus  through  the 
Eustachian  tube  can  account  for  intestinal  disturbances 
observed  in  such  children. 

It  is  not  easy  to  diagnose  this  inflammation  of  the  ear 
in  the  infant.  The  small  meatus  permits  only  the  use  of 
the  smallest  speculum.  Ver}-  strong  light  is  hence  re- 
quired. The  meatus  is  apt  to  be  filled  by  epidermis 
scales,  which  it  is  better  to  scoop  out  gently  than  to 
remove  by  syringing.  The  drumhead,  very  oblique  at 
this  age,  is  not  easily  distinguished  from  the  posterior 
upper  wall  of  the  meatus.  It  is  relatively  little  con- 
gested, but  more  turbid  on  account  of  the  exudate  than 
normally.  It  is  yet  to  be  determined  by  future  observ^a- 
tions  how  much  this  concomitant  otitis,  with  its  nearly 
latent  course,  adds  to  the  danger  of  the  disease  which  it 
complicates.  Whether  or  not  to  puncture  the  drumhead 
is  also  an  open  question.  There  certainly  should  be 
more  systematic  attention  paid  to  the  ear  of  all  sick 
babies. 

Entirely  different  from  this  almost  latent  form  of  con- 
comitant otitis  is  the  ordinary  purulent  otitis,  with  per- 
foration, which  can  occur  in  infants  at  the  earliest  age, 
and  which  presents  the  pronounced  symptoms  to  be 
described  in  ^  356. 


SIMPLE   OTITIS    MEDIA.  463 

354.  A  latent  form  of  purulent  otitis  seems  to  be  the 
invariable  rule  in  all  cases  of  measles  even  when  no  pro- 
nounced aural  symptoms  are  observed.  In  every  fatal 
case  of  that  disease  examined  by  Bezold  and  his  assist- 
ants the  middle  ear  and  mastoid  pneumatic  spaces  were 
found  filled  with  pus.  Yet  the  great  majority  of  patients 
with  measles  present  no  clinical  symptoms  of  ear  disease. 
In  scarlet  fever  various  observations  on  a  more  limited 
scale  have  also  shown  at  least  a  frequent  coincidence  of  a 
clinically  latent  purulent  effusion  into  the  middle  ear. 
The  same  statement  applies  in  diphtheria. 

355.  Ti^iie  pyogenic  infiani?nation  of  the  middle  ear, 
which,  however,  does  not  lead  to  perforation  of  the  drum- 
head, is  observed  at  times  in  children  and  somewhat  less 
frequently  in  adults.  It  begins  with  slight  fever  and  sharp 
pain.  The  pain,  however,  is  not  continuous,  but  inter- 
mittent, generally  worse  at  night.  Fulness  and  deafness 
increase  gradually  during  a  few  days,  and  when  the  cli- 
max has  been  reached,  the  pain  subsides.  The  drurji- 
head  is  either  uniformly  reddened  or  at  least  congested 
in  its  upper  posterior  portion  (compare  Fig.  5,  Plate  II.). 
Auscultation  during  inflation  shows  the  presence  of  fluid 
in  the  middle  ear.  During  healing  this  fluid  becomes 
absorbed. 

This  form  of  otitis  without  perforation  (which  is  not 
generally  recognized)  has  been  described  by  Politzer  as  a 
type  of  disease  not  identical  with  the  ordinary  perforating 
form  of  otitis.  According  to  my  experience,  it  is  really 
but  a  milder  type  of  the  same  disease  which  usually 
causes  the  drumhead  to  give  way,  but  perhaps  with  a  dif- 
ferent localization.  It  occurs  mainly  in  connection  with 
the  milder  forms  of  nasal  or  pharyngeal  disturbances. 
Coryza  or  tonsillitis,  especially  in  the  presence  of  ade- 
noids, may  lead  to  involvement  of  one  or  both  ears.  It 
may  last  from  one  to  more  than  two  weeks.  The  dis- 
tinction between  this  form  and  purulent  otitis  tending  to 
perforation  is  based  at  first  upon  the  intermittent  charac- 
ter of  the  pain.     The  distinction  is  not  a  difficult  one 


464  SIMPLE    OTITIS    MEDIA. 

when  the  drumhead  is  only  partially  injected,  but  un- 
certain when  it  is  diffusely  vascularized.  Subsequently 
the  diagnosis  is  established  by  the  subsidence  of  the 
symptoms  without  perforation  of  the  drumhead.  The 
disease  differs  from  exudative  catarrh  by  the  more  pro- 
nounced inflammatory  symptoms  at  the  onset.  After 
these  have  subsided  the  difference  between  this  form 
and  acute  catarrh  is  not  so  pronounced.  The  exudate, 
however,  usually  scant,  is  never  as  tenacious  as  the 
catarrhal  secretion. 

The  tendency  to  recovery  is  decidedly  aided  by  rest 
and  protection  and  Eustachian  inflation.  The  symp- 
toms may,  indeed,  subside  as  promptly  after  a  single 
inflation  as  they  often  do  in  exudative  catarrh,  but  like 
in  the  latter  instance,  they  increase  again  until  the  next 
treatment.  Inflation  stops  the  sharp  pain  at  once.  In- 
stillation of  carbolated  glycerin  (10  per  cent.)  seems  to 
help  in  shortening  the  duration.  After  a  few  days  of 
treatment  inflation  sometimes  seems  without  further  in- 
fluence. Pneumomassage,  while  less  effective  in  its  im- 
mediate influence,  is,  however,  of  some  benefit  until 
the  hearing  becomes  normal.  Politzer  warns  against 
paracentesis  of  the  drumhead.  This,  indeed,  is  usually  un- 
necessary. But  with  the  more  recent  methods  of  guard- 
ing against  secondary  infection  through  the  meatus  by 
ab.solute  asepsis  and  gauze  drainage  paracentesis  does 
not  involve  the  risk  of  protracted  suppuration,  which 
Politzer  cautions  against  as  the  danger  attending  punc- 
ture of  the  drumhead  in  this  disease.  The  operation 
may  hence  be  done  when  the  case  does  not  show  a 
steady  improvement  under  treatment  by  inflation,  pro- 
vided inflammatory  symptoms  or  intratympanic  exuda- 
tion persist. 


CHAPTER   XL. 

ACUTE  PURULENT  OTITIS  MEDIA    (WITH  PERFORA- 
TION  OF   DRUMHEAD). 

356.  Acute  suppurative  inflammation  of  the  middle 
ear  is  a  disease  prevalent  at  all  ages,  but  most  common 
in  childhood  on  account  of  the  predominance  of  its 
causes  during  that  period.  As  the  course  of  the  disease 
is  quite  variable  according  to  its  etiologic  conditions,  it 
is  best  to  begin  with  a  review  of  its  causes. 

The  disease  is  caused  by  the  invasion  of  the  middle 
ear  by  pyogenic  microbes.  In  more  than  one-half  the 
cases  it  is  the  pneumococcus,  next  to  it,  the  streptococcus, 
less  often,  the  staphylococcus,  occasionally,  the  pneumo- 
bacillus  (Friedlander),  the  colon  bacillus,  or  the  bacillus 
pyocyaneus.  As  a  rule,  only  one  variety  of  germs  is 
present  originally,  but  in  neglected  cases  streptococci 
and  staphylococci  may  come  in  as  secondary  infection. 
The  invasion  takes  place  mostly  from  the  nasopharynx 
through  the  tube.  Much  less  common  is  the  infection 
from  the  external  meatus  in  consequence  of  traumatism, 
such  as  careless  removal  of  foreign  bodies  or  plugs  of 
wax,  or  as  the  result  of  extension  of  eczema.  Cold 
water  entering  through  a  previous  perforation  of  the 
drumhead  may  also  rekindle  an  otitis.  The  most  fre- 
quent starting-point  of  the  disease  is  acute  nasal  catarrh. 
It  is  popularly  believed,  and  not  improbable,  that  the 
extension  through  the  tube  may  be  due  to  "taking 
cold."  But  simple  uncomplicated  coryza  does  not  often 
infect  the  ear  unless  aided  by  other  conditions.  In 
nurslings  this  may  be  teething.  In  older  children  the 
presence  of  an  enlarged  pharyngeal  gland  is  the  predomi- 
nating factor  more  than  an)'  other.     Later  in  life  nasal 

30  465 


466  ACUTE    PURULENT    OTITIS    MEDIA. 

stenosis  favors  the  spreading  of  suppurative  rhinitis  to 
the  ear  of  the  same  side.  These  predisposing  conditions 
play  the  same  role  in  connection  with  the  nasal  inflam- 
mation accompanying  eruptive  fevers.  One  of  the  most 
frequent  underlying  conditions  is  scrofula,  but  its  in- 
fluence depends  largely  on  the  existence  of  the  enlarged 
pharyngeal  tonsil  so  common  in  this  affection.  Suppura- 
tive otitis,  often  quite  severe,  may  result  from  the  entrance 
of  water  through  the  tube  while  using  the  nasal  douche 
or  while  diving.  Acute  tonsillitis  is  not  a  rare  cause. 
Diphtheria  leads  to  clinically  manifest  otitis  only  in  a 
small  proportion  of  cases,  but  when  it  does  occur,  it  is 
of  a  severe  type.  It  is  more  often  the  streptococcus 
than  the  diphtheria  bacillus  which  reaches  the  ear  in 
diphtheria.  Scarlet  fever  infects  the  ear  often,  and, 
as  a  rule,  severely;  measles  much  less  frequently,  at 
least  clinically  manifest,  and  generally  not  so  severely. 
Rhinitis  during  small-pox,  typhoid  fever,  or  pneumonia 
may  likewise  extend  to  the  ear.  Influenza  produces 
relatively  often  ear  trouble,  either  a  streptococcus 
otitis  or  a  special  form  of  influenza  otitis,  which  will 
be  described  separately.  Nasopharyngeal  inflammation 
does  not  always  extend  along  the  lining  membrane  of 
the  tube  to  reach  the  ear.  In  some  cases  the  infection 
travels  through  the  lymph-spaces.  If  purulent  otitis 
does  ever  occur  through  direct  infection  of  the  middle 
ear  b}'^  way  of  the  blood-current,  it  is  certainly  not 
common. 

Of  the  various  causes  of  otitis,  simple  nasopharyngeal 
inflammation  leads,  as  a  rule,  to  the  mildest  type,  espe- 
cially in  young  children.  The  ear  disease  following 
scarlet  fever  and  diphtheria  represents,  on  the  other 
hand,  the  most  severe  and  destructive  form.  Of  the 
various  causative  germs,  the  streptococcus  produces  the 
most  severe  infection. 

357.  The  morbid  changes  are  those  of  purulent  in- 
flammation in  general — viz.,  inflammatory  swelling  of 
the  mucous  membrane,  with  partial  destruction  of  the 


MORBID    CHANGES.  46/ 

epithelium  and  with  abundant  secretion  of  serum,  sero- 
purulent  fluid,  or  thick  pus.  The  most  purulent  form 
of  discharge  is  usually  due  to  streptococcus  infection. 
The  process  may  be  very  superficial  or  may  extend  into 
the  periosteal  layer.  In  the  latter  case  secondary  caries 
or  necrosis  of  the  bony  walls  or  of  the  ossicles  may 
follow  in  severe  instances.  In  all  but  the  mildest  cases 
the  inflammation  extends  into  the  mastoid  antrum,  and, 
as  a  rule,  the  same  discharge  is  found  in  this  cavity  as  in 
the  tympanum.  The  attic  is  probably  but  little  involved 
in  the  case  of  mild  superficial  lesions,  while  in  unfavor- 
able instances  it  may  be  the  principal,  or  at  least  the 
most  persisting,   seat  of  the  disease. 

358.  Acute  purulent  otitis  begins  with  sudden  fever, 
the  height  of  which  is  variable,  depending  somewhat  on 
the  preexisting  local  or  systemic  disturbance  which  caused 
the  otitis.  The  fever  does  not,  as  a  rule,  last  long,  espe- 
cially in  adults.  A  subsequent  sudden  rise  of  tempera- 
ture, however,  indicates  some  new  extension — for  in- 
stance, the  deeper  involvement  of  the  mastoid  process. 
The  accompanying  febrile  disturbances,  malaise,  loss  of 
appetite  and  so  forth  are  somewhat  variable,  but  gener- 
ally not  severe. 

In  very  rare  instances  severe  symptoms  may  occur 
which  simulate  brain  disease,  especially  in  children. 
Stupor,  delirium,  even  convulsions  are  sometimes  due  to 
otitis  without  cranial  complication,  and  cease  as  soon  as 
the  drumhead  is  perforated.  Examination  of  the  ear 
should  be  imperative  in  all  obscure  instances  of  apparent 
brain  disease,  especially  in  children  who  cannot  tell  of 
their  earache. 

The  predominating  symptom  is  pain, — earache, — often 
very  severe  and  radiating,  generally  with  more  or  less 
headache  (one-sided).  There  is  tenderness  around  and 
behind  the  ear,  extending  underneath  the  jaw,  and 
often  pain  on  swallowing.  The  pain  lasts  until  the  dis- 
charge finds  its  way  through  the  drumhead.  In  severe 
cases,  however,  pain  may  persist  for  hours  or  even  days 


468  ACUTE    PURULENT    OTITIS    MEDIA. 

after  perforation.  The  persistence  of  pain  with  tender- 
ness over  the  mastoid  region  should  arouse  the  suspicion 
of  mastoiditis.  In  the  most  destructive  instances  of 
otitis  during  scarlet  fever  pain  is  sometimes  conspicuously 
absent,  or  at  least  not  mentioned  by  an  apathetic  child, 
which  important  fact  should  not  be  forgotten  by  the  gen- 
eral practitioner.  Pain  is  likewise  absent,  as  a  rule,  in 
relapses  of  suppurative  otitis  in  ears  with  a  persisting 
perforation  in  the  drumhead.  The  ear  feels  full  and 
stuffy  until  well  along  in  the  course  of  recovery.  There 
is  rarely  any  tinnitus,  but  this  sometimes  follows  for  a 
while  after  the  cessation  of  discharge.  The  hearing  may 
be  but  little  affected  during  the  first  day  or  two.  Subse- 
quently it  becomes  dull  in  proportion  to  the  severity  of 
the  disease.  There  is  but  little  improvement  in  the 
hearing  by  the  time  the  discharge  has  ceased.  But  it 
can  be  safely  predicted  that  normal  hearing  will  return 
in  the  course  of  weeks,  perhaps  as  late  as  six  weeks  after 
the  attack,  except  in  the  case  of  extensive  destruction 
or  neglected  treatment. 

Perforation  of  the  drumhead  with  the  appearance  of 
discharge  gives  relief  to  the  pain,  as  a  rule,  but  not  in- 
variably. Perforation  rarely  occurs  in  less  than  thirty- 
six  to  forty-eight  hours;  exceptionally  as  late  as  the 
fourth  or  fifth  day.  It  cannot  be  too  strongly  emphasized 
that  the  discharge  is  in  most  instances  serous  at  first.  If 
not  properly  drained,  it  is  apt  to  become  purulent  after  a 
few  days  in  all  but  the  mildest  cases.  This  change  is 
partly  due  to  insufficient  drainage,  as  it  can  be  prevented 
by  a  properly  maintained  gauze  drain.  Later  on  the 
purulency  is  often  the  result  of  secondary  infection  by 
other  bacteria  invading  the  fluid  in  the  meatus.  It  is 
possible  and  it  should  be  the  aim  of  the  surgeon  to  keep 
the  serous  discharge  serous  and  not  to  let  it  get  purulent. 
In  many  severe  instances,  however,  especially  those  due 
to  streptococci,  the  discharge  is  purulent  when  it  first 
breaks  through  the  drumhead,  or  even  when  a  relatively 
early   paracentesis   is   performed.       Still,   in   even   such 


SYMPTOMS.  469 

instances  it  is  an  open  question  whether  opening  the 
drumhead  at  the  very  start  would  not  have  shown  a 
serous  efiusion.  The  discharge  may  be  very  profuse — as 
much  as  several  ounces  in  twenty-four  hours.  After  two 
to  three  days  it  begins  to  diminish  gradually  in  quantity. 
The  drumhead  is  uniformly  and  deeply  injected  from 
the  start  (compare  Fig.  7,  Plate  II.).  All  details  of 
structure  are  effaced;  the  manubrium  is  generally  not 
distinct.  Sometimes  circumscribed  purulent  pouches 
appear  (Fig.  130).  The  spontaneous  perforation  is  gen- 
erally not  larger  than  a  pinhole,  and  occurs  mostly  be- 
hind the  umbo,  often  quite  high  up.  In  inflammation 
localized  principally  in  the  attic  the  perforation  occurs 
in   the  flaccid   portion    or   Shrapnell's   membrane,    and 


Fig.  130. — Acute  otitis;  membrana  tympani  congested,  especially  in  upper 
posterior  quadrant,  serous  infiltration  almost  effacing  all  landmarks.  Circum- 
scribed bulging  in  upper  posterior  quadrant. 

this  region  may  remain  reddened  longer  than  the  rest  of 
the  drumhead  in  such  cases.  In  the  destructive  forms  due 
to  scarlet  fever  or  diphtheria  and  those  following  trauma- 
tism the  hole  in  the  membrana  tympani  is  apt  to  grow 
by  sloughing  of  its  edges.  In  other  forms  this  is  rarely 
the  case.  The  drop  of  fluid  seen  in  the  perforation  pul- 
sates. When  the  discharge  is  thick,  a  view  of  the  per- 
forated drumhead  can  be  obtained  only  after  cleansing 
by  syringing  or  mopping  with  cotton.  In  the  course 
of  recovery  the  drumhead  gets  pale,  but  often  remains 
thickened  and  cloudy  (compare  Figs.  8  and  6,  Plate  II.). 
Small  perforations  close  almost  invariably  if  the  disease 
does  not  become  chronic;  even  large  holes  do  so  very 
often.  Drainage  through  the  perforation  is  in  rare  in- 
stances interfered  with  by  a  singular  unfavorable  change 


470  ACUTE    PURULENT    OTITIS    MEDIA. 

— viz.,  a  nipple-like  prominence  of  granulation  tissue, 
with  a  narrow  fistula  in  it  which  projects  from  the  hole 
in  the  membrana  tympani.  This  occurs  often  in  disease 
of  the  attic  with  perforation  through  Shrapnel I's  mem- 
brane. It  is  best  to  remove  this  nipple  by  means  of  the 
snare,  or  even  a  small  galvanocaustic  burner  (Fig.  131). 

The  duration  of  the  disease  varies  with  the  etiology, 
severity,  and  to  some  extent  with  the  age  of  the  patient, 
and  especially  with  the  treatment.  In  a  teething  baby  the 
earache  of  one  night  may  be  followed  by  three  days  of 
discharge  and  recovery.  An  attack  of  moderate  severity 
in  a  grown-up  child  or  adult  rarely  lasts  less  than  ten  to 
fifteen  days,  and  often  three  to  four  weeks  if  the  discharge 
is  allowed  to  become  purulent.     Indefinite  perpetuation 


Fig.  131. — Membrana  tympani  in  acute  purulent  otitis  after  a  spontaneous 
perforation  has  become  obstructed  by  granulations  in  the  form  of  a  pouting  nipple. 
This  projection  is  hollow,  and  there  is  a  drop  of  pus  at  its  orifice.  The  membrana 
tympani  is  cloudy  and  thickened,  but  its  congestion  is  beginning  to  subside. 

of  the  disease  in  the  chronic  form  may  happen  in  almost 
any  case.  It  is  least  likely  in  very  young  children;  most 
likely  in  adults.  Mild  cases  are,  as  a  rule,  self-limited, 
but  when  the  disease  is  due  to  scrofula,  measles,  scarlet 
fever,  diphtheria,  or  influenza,  or  when  the  patient  is  ill- 
nourished  or  anemic,  spontaneous  termination  is  much 
less  likely.  Adenoid  vegetations  and  nasal  stenosis,  as 
well  as  chronic  nasal  suppuration,  favor  persistence  and 
relapses.  Suppuration  of  the  attic  is  especially  Ifable  to 
become  chronic.  Chronicity  can  in  every  case  be  pre- 
vented by  appropriate  treatment,  which  may  in  some 
few  instances  include  a  mastoid  operation. 

359.  Of  complications  of  purulent  otitis,  acute  mas- 
toiditis is  the  most  common;     All  but  the  mildest  forms 


TREATMENT.  47 1 

of  inflammation  of  the  middle  ear  are  accompanied  by 
some  inflammation  of  the  mucous  membrane  of  the  mas- 
toid antrum.  This  condition  may  be  clinically  latent,  or 
if  more  severe,  may  reveal  itself  by  more  or  less  tender- 
ness over  the  mastoid  region.  In  favorable  cases  this 
subsides  gradually,  but  in  some  it  may  increase  until 
finally  the  indications  of  disease  of  the  mastoid  bone 
appear  in  the  form  of  pain,  tenderness,  redness,  and  ex- 
ternal swelling.  The  detailed  description  will  be  given 
in  the  chapter  on  Mastoiditis.  Paralysis  of  the  facial 
nerve  is  a  very  infrequent  complication,  but  is  sometimes 
due  to  a  destructive  lesion  in  the  bone.  The  facial  palsy 
ends  in  recovery  after  the  lapse  of  a  number  of  weeks,  or 
even  some  months.  Intracranial  complications  are  much 
less  common  in  acute  than  in  chronic  purulent  otitis. 
The  small  fatality  of  acute  purulent  otitis,  probably 
much  less  than  0.5  per  cent.,  is  mainly  due  to  menin- 
gitis. The  symptoms  of  meningitis  may  exception- 
ally, however,  be  simulated  by  the  ear  disease  itself, 
and  disappear  when  the  pus  escapes.  Cerebral  ab- 
scess is  even  less  frequent  than  meningitis.  Throm- 
bosis of  the  lateral  sinus  with  pyemia  is  likewise  a 
remote  possibility,  not  nearly  so  common  as  in  the 
course  of  chronic  ear  disease.  Yet,  however  unlikely 
these  complications  are,  they  add  some  gravity  to  the 
prognosis  of  any  individual  case.  The  symptoms  of 
these  complications  will  be  found  in  Chapter  XLV. 

360.  The  treatment  of  acute  purulent  otitis  is  efficient 
only  if  based  on  the  surgical  principles  applicable  in  the 
management  of  suppuration  in  general — viz.,  drainage 
and  prevention  of  secondary  infection.  All  other  forms 
of  treatment  are  to  be  condemned  as  inferior.  The  pa- 
tient should  be  put  at  rest  during  the  acuteness  of  the 
symptoms.  After  they  have  moderated  and  drainage 
has  begun,  there  is  no  further  advantage  in  complete 
quietude.  The  pain  ceases  mostly  as  soon  as  the  dis- 
charge can  escape,  though  it  sometimes  persists  for  a 
while  after  perforation.     The  pain  may  require  palliative 


472  ACUTE    PURULENT    OTITIS    MEDIA. 

treatment.  Its  radiation  and  the  accompanying  headache 
can  usually  be  controlled  by  antipyrin.  Severe  earache 
itself  may  necessitate  morphin  or  opium.  Hot  applica- 
tions (the  hot-water  bag  or  the  Japanese  stove)  often  give 
some  relief  The  only  local  application  which  some- 
times mitigates  the  pain  before  perforation  is  carbolated 
glycerin  (lo  per  cent,  solution).  In  mild  cases  of  otitis 
permanent  relief  is  sometimes  seen  after  the  use  of  this 
fluid  in  the  form  of  a  prolonged  ear-bath.  But  this  is 
true  only  of  those  instances  which  do  not  end  in  per- 
foration of  the  drumhead.  Whether  the  use  of  carbolated 
glycerin  can  mitigate  the  disease  so  as  to  avert  perfora- 
tion is  an  open  question.  All  popular  ear  drops,  cam- 
phorated oil,  laudanum,  and  the  like,  are  entirely  useless 
and  delay  necessary  intervention.  Eustachian  inflation 
may  give  momentary  relief,  but  is  never  of  any  perma- 
nent benefit.  It  has  been  severely  condemned — perhaps 
unnecessarily  so — by  many  recent  observers  as  dangerous 
on  the  ground  that  it  may  carry  the  infected  material 
into  hitherto  healthy  spaces. 

Paracentesis  should  be  performed  at  once  as  soon  as  all 
hope  must  be  abandoned  of  regarding  the  case  as  one  of 
non-perforating  otitis.  When  severe  pain  has  lasted  with- 
out intermission  for  more  than  about  eight  hours  and  the 
diagnosis  is  apparent  by  the  uniform  redness  of  the  drum- 
head, it  is  the  safest  and  wisest  plan  to  puncture  imme- 
diately. The  operation  is  free  from  danger,  requires  no 
special  skill,  gives  quick  relief,  and  assures  the  shortest 
possible  course.  It  should  be  done  with  the  broad 
paracentesis  needle  or  bistoury  (Fig.  123)  in  the  most 
prominent  part  of  the  membrane  or  in  the  inferior 
posterior  region.  When  the  disease  is  limited  to  the 
attic,  as  shown  by  the  localized  vascularity,  Shrap- 
nelPs  membrane  should  be  divided  horizontally.  Too 
large  an  incision  is  better  than  too  small  a  cut.  There 
is  a  momentary  sharp  pain,  which  cannot  be  prevented 
by  anything  except  general  narcosis,  which,  as  a  rule,  is 
superfluous.      The    bleeding    is    insignificant.       Before 


TREATMENT. 


473 


the  paracentesis  the  meatus  should  be  cleansed  of  wax 
and  dust  by  syringing,  and  thereupon  sterilized  by 
filling  it  and  the  concha  for  at  least  three  minutes  with  a 
solution  of  carbolic  acid  in  water  (3  per  cent.)  or  in  gly- 
cerin (10  per  cent.).  After  paracentesis  the  meatus  should 
be  packed  with  a  strip  of  sterile  gauze  about  i  cm.  wide 
and  10  to  15  cm.  long,  pushed  through  the  (sterilized) 
speculum  gently  with  a  flat  probe.  The  entrance  to  the 
meatus  and  the  grooves  in  the  auricle  are  then  loosely 
filled  with  strips  of  gauze  until  enough  of  a  pad  has  been 
formed  to  absorb  the  most  copious  discharge  for  at  least 
half  a  day.  If  necessary,  this  is  held  in  place  by  a  nar- 
row strip  of  adhesive  plaster  across  the  auricle.  As  often 
as  the  external  pad  of  gauze  gets  moist  it  should  be  re- 
placed, which  the  patient  can  do  himself  The  strip  in 
the  meatus  should  be  replaced  only  by  the  surgeon  at  in- 
tervals of  one  or  two  days.  As  it  is  impossible  to  assure 
asepsis  by  means  of  sterile  gauze  alone,  various  antiseptic 
additions  have  been  tried,  which,  however,  must  be  non- 
irritating.  Chinolin-naphthol  gauze  is  lauded  by  some. 
The  writer  has  been  well  satisfied  with  a  powder  of  boric 
acid  mixed  with  one-sixth  of  salicylic  acid  dusted  freely 
into  the  meshes  of  the  gauze.  A  freely  absorbing  gauze 
must  be  selected,  since  the  object  of  the  dressing  is  to 
remove  the  discharge  as  fast  as  it  forms.  When  the  fluid 
is  serous,  this  is  easily  accomplished.  A  change  of  serous 
discharge  into  pus  indicates  inefficiency  of  the  surgeon's 
antiseptic  precautions  and  means  a  serious  prolongation 
of  the  disease.  When  the  fluid  is  purulent  from  the 
start,  the  strip  of  gauze  in  the  meatus  must  be  changed 
oftener,  in  order  to  maintain  a  continuous  flow  from  the 
middle  ear  to  the  surface  of  the  absorbing  pad.  Syring- 
ing is  of  no  benefit  whatsoever  in  this  disease.  If  done 
with  ordinary  water,  it  may  even  cause  secondary  infec- 
tion. Syringing  with  sterile  water  or  salt  solution  is  less 
harmful  and  may  sometimes  be  called  for  when  thick  dis- 
charge has  not  been  properly  absorbed  by  the  dressing. 
In  the  case  of  purulent  discharge  maceration  of  the  skin 


474  ACUTE    PURULENT    OTITIS    MEDIA. 

of  the  meatus  is  at  times  annoying.  The  skin  should  be 
cleansed  by  mopping  with  wet  and  subsequently  with  dry 
sterile  cotton  and  brushed  with  a  2  or  4  per  cent,  solution 
of  nitrate  of  silver.  Anointing  the  wall  of  the  meatus 
with  a  thick  zinc  oxid  ointment  is  also  of  service.  The 
regular  dressing  should  thereupon  be  replaced  in  the 
usual  way.  As  the  discharge  diminishes,  the  amount  of 
gauze  may  be  lessened  and  the  intervals  of  dressing 
lengthened.  By  the  time  the  fluid  has  become  scant, 
its  secretion  usually  ceases  abruptly.  In  cases  properly 
treated  according  to  this  method  from  the  start  relapses 
of  the  disease  are  almost  unknown  and  complications  quite 
infrequent.  When  the  discharge  has  ceased,  the  hearing 
is,  as  a  rule,  still  very  much  impaired.  Spontaneous 
recovery  follows,  however,  in  the  course  of  weeks  without 
further  treatment.  After  closure  of  the  perforation  Eu- 
stachian inflation  and  pneumomassage  are  sometimes  of 
some  service. 

When  spontaneous  perforation  has  occurred,  the  mildest 
and  shortest  possible  course  can  be  expected  only  if  the 
same  mode  of  dressing  is  begun  while  the  discharge  is 
still  serous.  If  it  has  changed  into  pus,  either  from  the 
continued  influence  of  the  original  germ  or  by  secondary 
infection  after  other  germs  have  entered  through  the 
meatus,  a  more  prolonged  course  must  be  expected  and 
complications  are  more  to  be  feared.  As  soon  as  the 
patient  is  seen  after  the  spontaneous  perforation,  the 
meatus  should  be  cleansed  by  aseptic  syringing  and  an 
effort  may  be  made  to  combat  secondary  infection  by  a 
prolonged  ear-bath  with  carbolated  glycerin.  The  pre- 
viously described  dressing  should  then  be  applied,  and 
the  case  managed  as  detailed  in  the  preceding  paragraph. 
Any  deviation  from  these  rules  will  only  result  in  a  less 
favorable  course. 

After  spontaneous  perforation  and  occasionally  after  a 
paracentesis  made  too  small  or  narrowed  by  a  nipple  of 
granulation  tissue,  the  acute  symptoms  will,  in  excep- 
tional instances,  persist  or  return  until  a  larger  puncture 


INFLUENZA    OTITIS.  475 

is  made  in  the  drumhead.  When  this  treatment,  properly 
carried  out,  does  not  result  in  the  steady  subjective  im- 
provement and  diminution  of  discharge  in  the  course  of 
about  two  weeks,  it  is  safe  to  assume  that  there  is  destruc- 
tion going  on  within  the  mastoid  cavity,  even  if  there 
are  no  external  symptoms  of  mastoiditis.  This  arbitrary 
period  of  about  two  weeks  does  not  refer  to  the  length  of 
the  disease  or  to  its  original  date,  but  only  to  the  time 
during  which  its  symptoms  are  absolutely  stationary 
under  treatment.  In  such  cases  no  cure  can  be  obtained 
until  the  mastoid  antrum  is  opened. 

361.  Influenza  Otitis. — During  the  extensive  epi- 
demics of  ijifluenza  for  some  years  before  and  after  1890 
a  peculiar  form  of  middle-ear  inflammation  was  often  met 
with  early  in  the  course  of  that  disease.  It  was  due  to 
the  invasion  of  the  tympanic  cavity  by  the  influenza 
bacillus.  It  began  with  intense  pain,  often  radiating  in 
the  form  of  a  diffuse  neuralgia,  and  with  much  fulness 
and  often  dizziness.  Objectively  it  was  characterized  by 
hemorrhages  in  the  drumhead  and  presumably  the  tym- 
panic mucous  membrane.  Spontaneous  perforation  of 
the  membrane  did  not  always  occur.  When  it  did  per- 
forate or  when  it  was  tapped,  the  discharge  was  a  bloody 
serum.  In  spite  of  its  apparent  severity  this  form  of 
influenza  otitis  usually  ended  favorably  in  about  two 
weeks  or  less  if  not  interfered  with  by  any  active  treat- 
ment. Paracentesis  was  generally  not  necessary  or  bene- 
ficial. Of  late  years  this  form  of  disease  has  become 
uncommon.  It  is  well  known  that  the  entire  clinical  his- 
tory of  influenza  is  changing,  either  on  account  of  altered 
virulence  of  the  bacillus  or  on  account  of  partial  im- 
munity of  the  population.  Nowadays  the  usual  form  of 
influenza  otitis  is  a  late  severe  streptococcus  infection  of 
the  middle  ear,  with  the  ordinary  clinical  course  of  an 
intense  otitis. 


CHAPTER  XLI. 

MASTOIDITIS. 

362.  The  mastoid  antrum  participates  in  all  severe 
forms  of  purulent  inflammation  of  the  middle  ear.  This 
has  been  shown  by  autopsies,  and  is  strongly  suggested 
as  well  by  the  copious  secretion  found  in  many  forms  of 
purulent  otitis,  too  copious  indeed  to  be  furnished  by  the 
small  area  of  the  tympanic  cavity.  This  inflammation 
of  the  mastoid  mucous  membrane  may  not  reveal  itself 
at  all  clinically,  or  it  may  be  indicated  by  pain  and  ten- 
derness over  the  mastoid  process.  This  superficial  inflam- 
mation, however,  limited  to  the  mucous  membrane,  is 
not  the  pathologic  basis  of  what  is  ordinarily  called 
mastoiditis.  Whenever  symptoms  occur  which  the 
clinicist  interprets  as  mastoiditis,  they  are  due  to  an 
extension  of  pyogenic  inflammation  into  the  bony  sub- 
stance of  the  mastoid  process,  complicated  often,  but  by 
no  means  always,  with  caries  or  necrosis  of  the  bone. 
In  very  rare  instances  an  abscess  is  limited  to  some  of 
the  cells  underneath  the  antrum  and  does  not  extend  into 
the  latter. 

Primary  mastoiditis  is  very  rare  and  is  probably  an 
osteomyelitis  of  the  mastoid  bone.  As  a  rule,  mastoiditis 
is  secondary  to  purulent  otitis  media.  In  rare  instances 
it  follows  that  disease  after  an  interval  of  many  weeks 
after  apparent  cure  of  the  otitis.  As  a  rule,  it  is  a  com- 
plication during  the  continuance  of  an  acute  otitis  with 
purulent  discharge,  sometimes  beginning  suddenly  with 
a  chill,  more  often  developing  gradually.  In  a  small 
number  of  instances  of  severe  otitis,  especially  the  strep- 
tococcus variety,  mastoiditis  pursues  an  insidious  course, 
with  gradual  abatement  of  its  acute  symptoms,  continu- 
ing in  a  chronic,   but   none  the   less   dangerous,   form. 

476 


SYMPTOMS — COURSE.  477 

This  almost  latent  form  sometimes  changes  into  a  more 
acute  disease.  Mastoiditis  is  apt  to  be  very  destructive 
in  diabetic  patients. 

Clinically  manifest  mastoiditis  complicates  but  a  small 
percentage  of  cases  of  acute  otitis — probably  considerably 
under  5  per  cent.  It  is  not  quite  so  frequent  in  children 
as  in  young  adults.  It  is  noticeably  infrequent  among 
negroes.  The  direct  cause  is  not  clear.  It  is  not  usually 
due  to  occlusion  of  the  aditus,  for  this  is  quite  commonly 
found  patent  during  operation.  A  large  antrum  seems 
of  predisposing  influence.  The  germs  found  in  the  pus 
are  the  same  as  those  in  acute  otitis  (1  356). 

363.  Mastoiditis  rarely  begins  with  a  chill  and  a  rise 
of  temperature  during  the  subsiding  fever  of  otitis.  As 
a  rule,  it  simply  prolongs  the  otitic  fever  in  an  atypical 
manner.  Quite  often  it  causes  no  rise  of  temperature. 
The  characteristic  symptoms  are  pain  over  the  mastoid 
region  and  tenderness.  The  former,  variable  in  degree, 
is  rarely  absent,  but  may  subside  while  the  destructive 
process  continues  in  the  mastoid.  The  tenderness  is 
more  constant.  One-sided  headache  is  rarely  absent. 
As  the  inflammatory  process  extends  through  the  bone 
toward  its  surface,  edematous  swelling  and,  later  on, 
congestion  and  inflammatory  edema  of  the  soft  parts 
behind  the  ear  become  pronounced.  Of  great  signifi- 
cance, too,  is  the  steady  continuance  of  the  discharge 
from  the  ear,  without  diminution,  even  if  the  other 
symptoms  should  be  less  marked  or  receding.  An  in- 
fallible, but  not  constant,  sign  is  the  bulging  of  the 
posterior  upper  wall  of  the  meatus,  sometimes  with 
marked  redness. 

In  its  course  mastoiditis  may  present  the  following 
possibilities: 

1.  It  may  end  in  recovery  without  perforation  of  the 
bone. 

2.  It  may  lead  to  a  subperiosteal  abscess. 

3.  It  may  perforate  through  the  bone — (a)  on  the  ex- 
ternal surface  ;  (d)  on  the  anterior  surface  (posterior  wall 


478  MASTOIDITIS. 

of  the  meatus)  ;  (c)  on  the  internal  surface  of  the  tip,  or 
(d)  the  inflammation  may  extend  through  the  bone  to 
the  cranial  contents. 

4.   It  may  become  chronic. 

364.  Recovery  without  perforation  is  probably  the 
most  common  termination  in  all  those  instances  of 
mastoiditis  in  which  there  is  no  destruction  of  bone. 
This  fortunate  turn  becomes  less  and  less  probable  when 
pain  and  tenderness  have  continued  about  a  week.  It 
may  be  excluded  after  pronounced  inflammatory  edema 
of  the  soft  parts  has  lasted  for  more  than  a  day  or  two. 
Edema  without  congestion  does  not  preclude  it.  Distinct 
bulging  of  the  posterior  upper  wall  of  the  meatus  is  a 
sure  sign  that  such  recovery  is  impossible. 

365.  A  subperiosteal  abscess  as  a  sequel  of  mastoiditis 
is  sometimes  seen  in  children  ;  less  often  in  adolescence. 
The  pyogenic  infection  extends  outward  from  the  antrum 
through  the  squamomastoid  fissure,  which  closes  later  in 
life,  or  perhaps  through  vascular  channels.  The  abscess 
does  not  communicate  with  the  mastoid  antrum.  As  a 
rule,  the  symptoms  of  mastoiditis  are  very  mild  in  such 
cases.  The  primary  otitis  may  even  have  ceased  when  a 
subperiosteal  inflammatory  swelling  appears  over  the 
mastoid  process,  generally  some  distance  behind  the  ear. 
When  this  is  properly  opened,  it  heals  kindly.  In  cor- 
rectly diagnosticated  cases  the  opening  of  the  mastoid 
bone  is  entirely  uncalled  for.  It  is,  however,  sometimes 
impossible  to  distinguish  between  these  comparatively 
innocent  abscesses  and  the  more  serious  spontaneous 
perforation  through  the  bone.  When  distinct  and  pro- 
tracted symptoms  of  mastoiditis  have  preceded  the 
accumulation  of  pus  under  the  soft  tissues,  it  is  well  to 
make  the  incision  large  enough  to  search  for  a  fistula  in 
the  bone.  In  early  childhood  and  in  those  instances  in 
which  an  early  perforation  indicates  a  thin  bony  wall  of 
the  antrum  the  patient  may  do  quite  well  after  a  simple 
incision  down  to,  but  not  into,  the  bone.  But  in  older 
patients  and  in  the  case  of  narrow  long  fistulae  the  heal- 


PERFORATION   IN    MASTOIDITIS.  479 

ing  is  more  protracted  and  the  course  not  so  free  from 
danger  as  after  a  proper  opening  into  the  bone. 

366.  Impending  perforation  is  indicated  by  inflamma- 
tory swelling  of  the  soft  parts  behind  the  ear.  They 
may  be  thickened  to  three  or  four  times  the  normal 
extent.  The  ear  may  stand  out  nearly  at  a  right  angle 
to  its  normal  plane.  By  carious  corrosion  of  the  bony 
wall  the  pus  finds  its  way  from  the  antrum  to  the 
exterior  of  the  bone,  raises  the  periosteum,  and  after  the 
lapse  of  a  good  many  days  breaks  through  the  skin. 
There  is  in  such  cases  at  least  a  carious  fistula  leading 
into  the  antrum.  There  may  be  necrosis  of  a  small  or 
large  area  of  the  external  plate,  or  there  may  even  be  a 
sequestrum  in  the  antrum.  The  latter  is  usually  filled 
with  spongy  granulations  which  bleed  freely  on  touch. 
The  pus  found  in  the  cavity  is  thick  and  creamy.  It 
may  be  scant,  but  more  often  a  large  or  morbidly  en- 
larged antrum  contains  it  in  abundance.  In  severe 
instances  the  destructive  inflammation  extends  through- 
out all  the  pneumatic  spaces  of  the  entire  bone.  In  rare 
cases  the  antrum  itself  is  not  involved,  the  disease  being 
limited  to  some  cells  in  the  mastoid  process  below  the 
antrum.  When  perforation  has  taken  place  through  a 
narrow  fistula  without  free  drainage,  the  dangers  of 
mastoiditis  are  merely  lessened,  but  not  removed. 

Perforation  through  the  anterior  wall  into  the  meatus 
does  not  take  place  often,  even  where  bulging  of  the 
wall  of  the  meatus  shows  the  action  of  pent-up  pus. 
When  an  opening  occurs  through  the  anterior  boundary 
of  the  mastoid  antrum,  the  pus  is  more. apt  to  burrow 
underneath  the  cartilaginous  meatus  to  the  exterior  than 
to  appear  in  the  meatus  itself 

In  the  case  of  a  markedly  pneumatic  mastoid  process 
the  inflammation  may  extend  throughout  all  the  cells  to 
the  tip,  and  if  the  inferior  inner  wall  is  thin,  perforation 
can  occur  here  underneath  the  sternomastoid  and  scale- 
nus muscles.  This  relatively  infrequent  occurrence  is 
known  as  Bezold's  perforation.     The  pus  burrows  under- 


480  MASTOIDITIS. 

neath  the  muscles  and  cervical  fascia,  forming  a  deep 
abscess.  If  this  does  not  open  spontaneously  or  is  re- 
lieved by  the  knife,  it  may  extend  into  the  anterior  or 
posterior  mediastinal  space,  with  fatal  result.  With  deep 
incision  and  good  drainage  the  prognosis  is  otherwise  not 
bad,  provided  the  mastoid  process  be  well  opened. 

367.  The  greatest  danger  of  mastoiditis  is  the  exten- 
sion of  pyogenic  infection  upward.  This  may  occur 
even  after  spontaneous  perforation  outward  if  the  pus 
does  not  find  free  exit.  Sometimes  a  carious  spot  is 
formed  in  the  roof  of  the  antrum.  In  other  cases  the 
inflammation  extends  through  the  thin  or  even  normally 
defective  plate  of  bone,  separating  the  antrum  from  the 
posterior  cranial  fossa.  The  possible  consequences  are 
phlebitis  with  bland  or  purulent  thrombosis  of  the  lateral 
sinus,  serous  or  purulent  meningitis,  subdural  (epidural) 
abscess,  or  intracerebral  abscess.  The  description  of 
these  diseases  will  be  found  in  Chapter  XLV.  In  chil- 
dren the  thicker  antral  roof  makes  the  upward  extension 
much  less  common  than  in  adults. 

368.  In  a  small  number  of  instances  the  acute  symp- 
toms of  a  mastoiditis  subside  wholly  or  in  part  without 
recovery,  and  the  inflammation  continues  in  a  chronic 
form.  There  may  or  may  not  be  some  pain  left.  The 
tenderness,  however,  disappears.  The  only  symptom  is 
the  persistence  of  the  discharge  from  the  ear,  which  resists 
all  forms  of  treatment  except  opening  of  the  mastoid 
process.  This  chronic  condition  may  continue  indefi- 
nitely as  a  form  of  chronic  purulent  otitis,  but  is  apt  to 
exacerbate  at  times  in  a  subacute  form.  In  these  cases 
the  mastoid  process  is  often  found  sclerotic,  probably  in 
consequence  of  the  long-continued  inflammation. 

369.  The  treatment  should  be,  in  the  first  place,  pre- 
ventive. The  liability  to  mastoiditis  is  least  when  a 
purulent  otitis  receives  proper  attention  and  drainage 
from  the  start.  In  my  own  experience  clinically  mani- 
fest mastoiditis  has  never  occurred  as  long  as  the  dis- 
charge  from  the   middle  ear   remained  serous.     But   it 


TREATMENT.  48 1 

is  not  correct  to  state  that  mastoiditis  can  always  be 
prevented,  for  in  some  instances,  especially  of  strepto- 
coccus otitis,  the  discharge  is  purulent  when  first  seen. 
At  the  onset  of  the  disease  rest  and  free  action  of  the 
bowels  are  desirable.  Some  authors  recommend  cold 
applications;  others  insist  on  heat.  In  all  probability 
neither  application  has  any  influence  upon  the  disease, 
but  heat  is  often  subjectively  agreeable.  It  may  be  ap- 
plied in  the  form  of  a  hot-water  bag  or  the  Japanese 
stove.  The  latter,  a  small  tin  box  heated  with  charcoal 
cartridges  and  sold  in  Chinese  stores,  is  a  very  pleasant 
way  of  making  warm  applications  lasting  about  two 
hours.  The  value  of  any  counterirritants  applied  to  the 
skin  is  less  than  problematic.  Subperiosteal  abscesses 
are  to  be  opened  by  a  deep  and  sufficiently  long  incision 
through  the  bulging  area.  This  may  be  done  even  with- 
out narcosis  or  after  freezing  with  ethyl  chlorid.  This 
cut,  known  as  Wilde's  incision,  is  all  that  is  required, 
provided  the  wound  be  properly  kept  open.  Wilde's 
incision  is,  however,  not  the  proper  treatment  for  a  col- 
lection of  pus  due  to  perforation  of  the  bone.  It  may 
answer  in  a  child,  but  where  a  narrow  long  fistula  ex- 
ists, the  latter  should  be  enlarged  by  gouging.  Wilde's 
incision  has  also  been  recommended  as  an  abortive 
measure  when  the  first  external  signs  of  mastoiditis 
appear.  On  account  of  the  uncertain  prognosis  of  the 
disease  at  that  time  it  is  difficult  to  estimate  the  efficacy 
of  this  procedure.  If  it  is  done  for  this  purpose,  it  should 
be  made  close  to  the  auricle,  so  that  it  can  be  utilized  for 
a  subsequent  bone  operation  if  required.  In  such  a  case 
it  is  absolutely  necessary  to  keep  the  wound  aseptic. 

Whenever  the  pain  and  tenderness  of  mastoiditis  have 
lasted  without  cessation  over  a  week;  whenever  inflam- 
matory swelling  of  the  soft  parts  has  persisted  for  more 
than  two  days,  or  when,  under  proper  treatment^  the  dis- 
charge of  acute  purulent  otitis  has  not  diminished  for 
about  ten  days  with  more  or  less  vague  manifestations  of 
mastoiditis,  recovery  without   artificial   opening   of  the 

31 


482 


MASTOIDITIS. 


bone  cannot  be  expected.  It  requires  good  judgment  to 
guard,  on  the  one  hand,  against  an  unnecessary  opera- 
tion, with  some,  though  a  small,  fatality,  and,  on  the 
other  hand,  not  to  defer  surgical  interference,  which  may 
save  the  life.  When  the  symptoms  of  mastoiditis  in- 
crease steadily  for  two  or  three  days,  or  when  any 
urgent  signs  of  cerebral  irritation  have  made  their  ap- 
pearance, an  operation  should  be  done  at  once. 

370.  The  opening  into  the  mastoid,  usually  known  as 
Scliwartze's  chisel  operation,   is  intended   to   reach    the 


LJ     ijs    LP    ui     tj    ki 

Fig.   132. — Chisels  for  opening  the  mastoid. 

antrum  by  the  shortest  possible  route.  It  consists  in 
cutting  a  passage  through  the  bone  more  or  less  parallel 
to  the  posterior  wall  of  the  meatus,  and  much  nearer  to 
the  superior  than  to  the  inferior  wall.  Experience  has 
shown  that  the  safest  tool  is  the  chisel,  of  which  the 
wider  ones  (10  to  12  mm.)  are  used  externally,  while  in 
the  depth  the  narrowest  ones  (3  to  5  mm.)  are  employed 
(Fig.  132).  The  mallet  is  filled  with  lead.  The  hole  in 
the  bone  is  made  funnel-shaped,  but  the  wider  this  fun- 
nel is  made  externally,  and  hence  the  shallower  its  depth, 
the  less  the  danger  of  accidental  injuries.     The  hole  in 


MASTOID   OPERATION.  483 

the  bone  should  begin  with  a  width  of  about  1.5  to  2  cm., 
but  this  aperture  may  be  widened  if  it  is  necessary  to 
enter  very  deeply.  The  external  opening  should  be  im- 
mediately behind,  and  its  center  2  or  3  mm.  below  the 
level  of  the  upper  wall  of  the  meatus.  The  upper  border 
must  be  below  the  linea  temporalis.  The  anatomic 
anomalies  to  be  feared  are  protrusion  of  the  sigmoid  fossa 
(lateral  sinus)  toward  the  antrum  or  low  level  of  the  mid- 
dle cerebral  fossa.  The  lateral  sinus,  generally  a  trifle 
lower  on  the  right  than  on  the  left  side,  is  usually  fully 
I  cm.  behind  and  slightly  above  the  posterior  upper  wall 
of  the  meatus.  The  more  pneumatic  the  bone  structure, 
the  greater  the  probability  of  a  normal  distance  between 
meatus  and  sinus;  the  more  compact  the  bone,  the  more 
likely  is  a  dangerous  proximity  of  the  sinus  to  the  meatus 
(see  Figs.  87,  89,  104  to  107).  In  extreme  cases  there 
may  only  be  a  distance  of  5  mm.  or  even  a  trifle  less 
separating  the  two.  The  exposed  sinus,  if  normal,  ap- 
pears as  a  bluish-gray  vessel,  the  walls  of  which  can  be 
easily  indented  by  the  probe.  The  danger  of  wounding 
the  lateral  sinus  is  least  if  the  chisel  is  only  directed 
downward  and  (alternatingly)  forward  after  the  first  few 
external  strokes.  The  shallowness  of  the  wound  is 
favored  by  resecting  the  external  portion  of  the  posterior 
wall  of  the  bony  meatus  by  chiseling  in  a  forward  direc- 
tion. It  should  be  the  aim  to  enter  the  antrum  at  its 
lowest  level.  As  soon  as  the  antrum  is  exposed,  any  in- 
tervening spongy  bony  substance  can  be  more  safely 
scooped  out  with  a  curet.  But  if  the  apex  of  the  conic 
hole  is  lower  than  the  center  of  the  meatus,  the  antrum 
will  generally  be  missed.  In  young  children  the  first 
few  strokes  of  the  chisel  suffice  to  break  down  the  thin 
external  wall.  In  adults  12  to  15  mm.  is  the  average 
depth  of  the  requisite  hole  in  the  bone  as  measured  from 
the  spina  supra  meatum^  a  short  spur  at  the  upper  poste- 
rior angle  of  the  entrance  of  the  exposed  bony  meatus,  a 
landmark  present  in  about  three-fourths  of  all  subjects. 
Measured  from  the  external  surface  of  the  mastoid  bone 


484  MASTOIDITIS. 

itself,  the  distance  is  more  variable.  As  soon  as  this 
distance  is  exceeded,  the  utmost  caution  is  required  in 
order  not  to  wound  the  facial  nerve  or  the  external  semi- 
circular canal.  When  the  antrum  is  not  reached  at  this 
depth,  careful  measurements  should  be  made  of  the  depth 
of  the  meatus  up  to  the  membrana  tympani,  and  if  at 


Fig.  133. — Operative  exposure  of  the  mastoid  antrum  in  a  moderately  pneu- 
matic process.  Appearance  after  completed  operation  and  before  closure  of  the 
wound, 

the  corresponding  distance  from  the  surface  of  the  mas- 
toid the  antral  cavity  is  not  found,  the  operation  should 
be  abandoned.  It  is  a  singular  and  not  yet  explained 
fact  that  a  number  of  cases  with  urgent  symptoms  have 
done  well  after  such  incomplete  operations  in  which  the 
diseased  cavity  was  not  reached  (Fig.  133). 


MASTOID   OPERATIOK.  485 

The  bleeding  on  cutting  the  soft  parts  varies  with  their 
congestion,  as  also  does  the  bleeding  from  the  bone. 
When  the  antrum  is  filled  with  granulations,  these  bleed 
very  profusely  until  thoroughly  scooped  out.  When  the 
sinus  is  accidentally  wounded,  a  big  gush  of  venous 
hemorrhage  occurs,  which  can  be  controlled  by  pres- 
sure with  gauze.  This  accident  has  usually  proved 
harmless  in  the  end,  but  it  may  necessitate  tempo- 
rary abandoning  of  the  operation  until  a  firm  clot  has 
formed  after  a  few  days.  Very  few  deaths  have  ever  oc- 
curred from  the  entrance  of  air  into  the  opened  sinus. 
Should  the  cerebral  plate  be  damaged  and  the  dura  ex- 
posed, no  evil  consequences  result,  as  a  rule,  if  the  opera- 
tion is  done  aseptically  and  all  sharp  spiculse  of  bone 
are  carefully  removed.  As  in  all  major  operations,  all 
details  regarding  asepsis  of  instruments,  the  hands  of  the 
surgeon,  and  of  the  field  of  operation  should  be  rigidly 
carried  out.  The  hair  should  be  shaved  far  beyond  the 
wound,  and  the  head  inclosed  in  sterile  towels  or  a  rub- 
ber cap.  The  instruments  required  are  scalpels,  scissors, 
several  forceps,  needles,  and  ligature  threads,  two  retrac- 
tors, a  periosteum  elevator,  a  set  of  chisels,  a  hammer, 
two  sizes  of  sharp  curets,  and  a  few  artery  forceps.  The 
several  steps  may  be  summarized  as  follows: 

General  anesthesia;  incision  down  to  the  bone,  i  cm.  be- 
hind and  parallel  to  the  auricle,  from  its  tip  to  the  end  of 
the  mastoid  process.  If  this  is  insufficient,  a  short  poste- 
rior transverse  cut  is  made  above  the  middle  of  the  wound. 
Arrest  of  bleeding  by  compression,  artery  forceps,  torsion, 
and  occasionally  a  ligature.  Bhint  detachment  of  the 
periosteum,  both  forward  and  backward.  Chiseling  of 
the  bone  with  successively  smaller  chisels,  at  first  from 
the  entire  periphery  toward  the  center  of  the  wound,  but 
subsequently  only  in  the  forward  and  downward  direction, 
and  merely  upward  from  the  lower  edge  with  care.  The 
chiseling  should  extend  through  the  posterior  wall  of  the 
meatus,  at  least  in  the  external  half.  If  a  carious  fistula 
shows  the  way,  this  path  should  be  followed  by  goug- 


486  MASTOIDITIS. 

ing.  As  soon  as  the  antrum  is  reached,  the  granula- 
tions usually  present  are  scraped  out  with  the  curet,  and 
the  bony  channel  is  smoothened  with  the  same  tool. 
The  purulent  infiltration  must  be  followed  as  far  as  it 
extends.  In  some  instances  it  is  necessary  to  gouge  out 
the  contents  of  the  entire  mastoid  process  through  the 
pneumatic  cells  to  the  tip.  It  is  best  to  remove  any 
overhanging  thin  cortical  shell  of  bone.  The  bleeding 
stops  soon  after  emptying  the  antrum.  In  recent  cases 
syringing  is  uncalled  for.  When  there  is  retained  and 
foul  pus,  it  is  better  to  irrigate  with  sterile  salt  solution. 
There  may  be  or  may  not  be  at  the  time  communication 
between  the  antrum  and  the  tympanic  cavity,  with  escape 
of  the  fluid  through  the  meatus.  Packing  of  the  wound 
in  the  bone  with  iodoform  gauze.  Suture  of  the  soft  parts 
above  and  sometimes  below  the  drain.  A  large  gauze 
pad  is  put  over  the  wound.  Meanwhile  the  ear  has  been 
filled  with  a  fresh  sterile  gauze  drain,  whereupon  the 
dressing  is  completed. 

When  a  carious  spot  is  found  leading  into  some  cells 
below  the  antrum,  and  on  scooping  them  out  nothing 
points  to  involvement  of  the  antrum  itself,  the  operation 
may  be  finished  at  this  point,  provided  the  clinical  signs 
did  not  clearly  indicate  empyema  of  the  antrum. 

371*  The  first  dressing  may  be  left  as  long  as  five  days 
if  neither  pain,  rise  of  temperature,  nor  excessive  dis- 
charge calls  for  its  removal.  The  subsequent  dressings 
should  also  be  chano^ed  onlv  at  the  long-est  intervals 
proper.  The  patient  is  kept  in  bed  for  a  few  days  until 
comfortable.  When  afebrile  from  the  start,  the  operation 
should  cause  either  no  rise  of  temperature  or  only  a  tran- 
sient mild  aseptic  fever.  After  a  properly  done  operation 
the  discharge  from  the  ear  ceases  very  speedily.  The 
discharge  from  the  wound  rarely  disappears  in  less  than 
two  to  three  weeks,  and  sometimes  as  much  as  six  or 
eight  weeks  are  required,  if  the  wound  is  not  wide  enough 
externally.  It  is  often  difficult  to  keep  the  wound  open, 
and  the  gauze  drain  should  not  be  dispensed  with  until 


MASTOID   OPERATION.  487 

the  wound  is  dry.  When  the  discharge  remains  offensive, 
which  is  very  rare,  it  is  better  to  depend  on  accurate  tam- 
poning than  on  syringing.  Attempts  have  been  made  to 
close  the  wound  by  a  complete  suture  and  to  let  it  heal 
under  a  blood-scab.  Although  this  may  often  be  success- 
ful in  the  hands  of  a  thoroughly  competent  surgeon,  it  in- 
volves considerable  risk.  It  is  proper,  however,  in  the 
case  of  an  incomplete  operation  in  which  the  antrum  is 
not  reached.  When  the  diminished  discharge  does  not  re- 
quire a  voluminous  dressing,  a  serviceable  form  of  band- 


FlG.  134. — Author's  bandage   for  mastoid  operations  after  the  discharge  has 
become  less  profuse. 

age  is  the  one  shown  in  Fig.  134,  which  is  kept  from 
becoming  distorted  by  the  insertion  of  whalebone  at  its 
two  edges,  while  the  bands  of  tape  prevent  it  from  slip- 
ping. 

The  mortality  of  mastoid  operations  is  below  8  per  cent, 
in  recent  years  ;  in  some  published  series  of  cases  even 
very  far  below  this  figure  or  nearly  zero.  The  majority 
of  deaths  are  due  to  the  extension  of  neglected  disease, 
and  only  a  small  proportion  of  the  accidents  can  be  as- 
cribed to  the  operation.  The  mortality  of  mastoiditis 
without  operation  is  not  known,  but  must  be  very  high. 


CHAPTER   XLII. 

CHRONIC  PURULENT  OTITIS  MEDIA. 

372.  Chronic  suppuration  of  the  middle  ear  is  the  se- 
quel of  acute  inflammation.  When  the  acute  symptoms 
— the  pain  and  the  feeling  of  stuffiness — have  subsided, 
and  when  the  amount  of  discharge  has  become  about 
uniform  for  a  number  of  weeks,  the  disease  can  be  called 
chronic  and  no  spontaneous  change  in  the  condition  can 
then  be  expected  except  in  the  course  of  long  periods  of 
time.  The  main  symptom  is  the  discharge.  This  is 
rarely  profuse,  generally  scant,  and  sometimes  so  minimal 
that  it  dries  in  the  form  of  crusts  which  the  patient  mis- 
takes for  wax.  It  is  always  purulent,  but  when  copious, 
it  is  apt  to  be  mucopurulent.  With  rare  exceptions  the 
discharge  is  offensive  in  smell — characteristically  fetid. 
The  rare  exceptions  are,  on  the  one  hand,  occasional  in- 
stances of  copious  thin  mucopurulent  fluid  ;  on  the  other 
hand,  a  very  scant  discharge  which  dries  in  the  form  of 
minute  crusts.  The  odor  of  the  discharge  should  always 
be  noted  by  mopping  the  meatus  with  a  small  pledget 
of  cotton,  as  its  persistence  or  yielding  under  treatment 
indicates  the  type  of  the  disease  and  determines  the  prog- 
nosis. When  the  discharge  is  so  scant  that  it  cannot  be 
seen  in  the  meatus,  it  should  be  looked  for  by  mopping 
with  cotton.  Even  if  this  test  fails,  suppurative  otitis 
should  not  be  excluded  in  suspected  cases  until  the  search 
for  small  flakes  of  pus  is  negative  in  the  water  with 
which  the  ear  has  been  syringed. 

The  impairment  of  the  hearing  is  very  variable  and 
depends  principally  on  the  destructiveness  of  the  inflam- 
mation during  the  acute  period.  The  deafness  may  be  so 
slight  that  the  patient  is  not  aware  of  it.     On  the  other 

488 


CHRONIC    PURULENT    OTITIS    MEDIA.  489 

hand,  the  ear  may  be  deaf  for  all  practical  purposes. 
The  deafness  does  not  depend  so  much  on  the  perforation 
of  the  membrana  tympani  as  on  the  adhesions  in  the 
attic,  or  between  membrana  tympani  or  ossicles  and  the 
internal  tympanic  wall.  Noises  and  stuffiness  are  rarely 
mentioned.  Dizziness  is  not  common,  but  when  present 
indicates  active  disease,  usually  in  the  attic  (or,  in  severe 
instances,  caries  of  the  labyrinth). 

373.  Chronic  purulent  otitis  may  remain  absolutely 
stationary,  or  may  spontaneously  heal  temporarily  or 
permanently  or  may  present  transient  subacute  exacerba- 
tions. 

In  the  course  of  time  and  under  favorable  environment 
an  otitis  which  has  remained  chronic  for  a  long  period 
may  finally  heal  without  intervention.  But  this  is  not 
common.  The  vicious  advice  so  often  given  by  physi- 
cians of  a  former  period  to  let  an  otorrhea  alone  was  not 
founded  on  correct  observations.  When  a  chronic  puru- 
lent otitis  has  healed,  either  spontaneously  or  in  conse- 
quence of  treatment,  relapses  may  be  expected  under  cer- 
tain conditions.  These  are  mainly  the  persistence  of  naso- 
pharyngeal lesions  which  caused  the  disease  in  the  first 
place,  especially  adenoid  vegetations,  and  less  frequently 
the  purulent  rhinitis  of  children.  Occasional  instances 
are  observed  in  which  a  discharge  from  the  ear  is  started 
with  every  severe  cold,  subsiding  afterward  even  without 
aid.  Independently  of  nasopharyngeal  lesions  relapses 
occur,  besides,  in  a  noticeable  proportion  of  patients 
apparently  cured  of  ear  suppuration  complicated  with 
cholesteatoma  or  caries  of  bone.  Whenever  a  purulent 
otitis  has  healed,  leaving  a  permanent  perforation  of  the 
drumhead,  a  subsequent  attack  of  purulent  infection  of 
that  ear  begins  always  in  a  mild  subacute  manner  and 
rarely  with  any  intense  acute  symptoms. 

The  most  serious  cases  of  chronic  purulent  otitis  are 
those  occasionally  subject  to  subacute  exacerbations. 
These  are  mainly  the  class  which  I  shall  describe  as 
the  type  of  purulent  otitis  with  retention  of  pus.     The 


490  CHRONIC    PURULENT    OTITIS    MEDIA. 

aggravations  vary  very  much  in  severity  and  danger. 
On  the  whole,  however,  their  danger  to  life  is  much 
greater  than  that  of  primary  acute  inflammations  of  a 
hitherto  normal  ear.  The  majority  of  instances  of  pye- 
mia and  of  intracerebral  complications  due  to  otitis  occur 
in  the  course  of  subacute  exacerbations  of  the  chronic 
disease.  Various  estimates  have  shown  that  about  j^,  to 
^  per  cent,  of  all  deaths  are  due  to  ear  disease,  mainly 
in  the  chronic  form  (in  European  statistics).  These  sta- 
tistics, however,  are  not  absolutely  trustworthy.  It  is 
worth  noting  that  many  life-insurance  companies  refuse 
applicants  with  chronic  purulent  otitis. 

374.  The  liability  of  an  acute  suppurative  otitis  to 
become  chronic  depends  on  the  severity  of  the  infection 
and  on  the  age  of  the  patient.  In  very  young  children 
it  is  only  the  severe  otitis  of  scarlet  fever  or  diphtheria 
which  is  likely  to  become  chronic,  or  perhaps  a  fre- 
quently recurrent  inflammation  due  to  adenoids.  In 
adults,  on  the  other  hand,  the  healing  of  an  otitis  with- 
out medical  aid  occurs  only  in  the  mildest  forms  of  in- 
flammation. The  direct  cause  of  chronicity  is  mainly 
the  stagnation  of  pus  with  secondary  infection  from  the 
meatus.  In  the  discharge  of  the  chronic  disease  the 
original  parasites  are  not  necessarily  present.  The  pneu- 
mococcus  has,  as  a  rule,  disappeared,  and  has  been  re- 
placed by  streptococci  and  staphylococci.  The  fetid 
odor  is  due  to  the  coexistence  of  putrefactive  bacilli. 
The  change  of  an  acute  otitis  into  the  chronic  form  indi- 
cates inefiicient  treatment.  I  am  pleased  to  have  noted 
the  gradual  diminution  in  the  proportion  of  chronic  puru- 
lent otitis  presenting  itself  for  treatment  in  the  course  of 
my  practice,  undoubtedly  due  to  the  better  training  of 
physicians  in  otology.  It  must  be  admitted,  however, 
that  some  cases  cannot  be  prevented  from  becoming 
chronic,   except  by  opening  the  mastoid. 

375.  Instead  of  an  unsystematized  description  of  the 
appearances  and  lesions  in  chronic  purulent  otitis  the 
author  prefers  to  classify  the  disease  under  several  heads, 


TYPES   OF   CHRONIC    PURULENT  OTITIS. 


491 


with  details  regarding  pathology  and  treatment  sub- 
divided correspondingly. 

We  can  distinguish  clinically  between — 

A.  Simple  chronic  purulent  otitis; 

B.  Purulent  otitis  with  retention  of  pus — (with  or 

without  complications). 

In  the  first  type  of  the  disease  the  suppurating  areas  are 
accessible,  and  the  fetor  of  the  discharge  is  readily  re- 
moved by  cleanliness.  In  the  second  type  there  is  reten- 
tion of  pus  coming  from  inaccessible  spaces,  and  the  sec- 
ondary infection  which  has  caused  the  odor  cannot  be 
controlled  by  syringing.  The  distinction  is  based  on 
pathologic  grounds,  but  it  can  in  some  instances  be  rec- 
ognized only  by  the  therapeutic  test.  In  describing  chronic 
purulent  otitis  we  must  furthermore  take  into  account  the 
absence  or  the  presence  of  complications — viz.,  polypi, 
bone  disease,  and  cholesteatoma. 

376.  In  simple  tmcomplicated  chronic  suppurative  otitis 
the  perforation  of  the  drumhead  seen  after  cleansing  is 
usually  of  moderate  size,   sometimes   round,   sometimes 


Fig.  135. — Large  kidney-shaped 
perforation  in  membrana  tympani  in 
chronic  purulent  otitis ;  drumhead 
thickened,  cloudy,  and  retracted ; 
manubrium  only  partly  visible;  tym- 
panic mucous  membrane  congested. 


Fig.  136. — Perforation  in  lower 
part  of  membrana  tympani  in  chronic 
purulent  otitis ;  membrana  tympani 
is  thickened  and  opaque ;  the  mu- 
cous membrane  of  the  inner  tym- 
panic wall  appears  dark  red  through 
the  perforation. 

oval,  sometimes  bean-shaped,  and  anywhere  in  the 
membrana  proper  (Figs.  135  and  136 — compare  Figs. 
10  and  II,  Plate  II.).  It  is  not  common  to  see  the 
small,  pin-hole-shaped  perforations  found  early  during 
acute  suppuration.     On  the  other  hand,  the  total  drum- 


492  CHRONIC    PURULENT   OTITIS. 

head  and  even  the  ossicles  may  have  been  destroyed  by 
the  primary  disease.  Perforations  in  Shrapnell's  mem- 
brane usually  indicate  the  type  of  otitis  with  retention. 
The  perforation  is  a  stationary  condition,  not  changing 
in  spite  of  the  persistence  of  suppuration.  Through  the 
hole  the  tympanic  mucous  membrane  is  visible,  being 
usually  reddened  while  the  discharge  lasts. 

In  default  of  postmortem  information  we  must  assume 
the  lesion  in  this  type  of  disease  to  be  a  superficial  in- 
flammation of  the  tympanic  lining  membrane.  The 
thickening  of  the  mucous  membrane  sometimes  seen 
through  large  perforations  can  only  be  due  to  inflam- 
matory infiltration.  No  other  lesions  could  disappear 
as  rapidly  under  treatment. 

377*  Both  as  a  diagnostic  test  and  as  a  therapeutic  meas- 
ure the  ear  should  be  syringed  very  thoroughly  at  the  first 
examination.  Accidental  observations  have  shown  me 
that  syringing  alone  can  cure  some  instances.  The 
water  should  be  pure  and  uncontaminated.  Sterility, 
while  theoretically  desirable,  does  not  seem  to  be  of 
practical  importance.  There  is  no  object  in  adding  anti- 
septics to  the  water.  The  time  of  their  action  is  too 
short  for  efficiency.  In  case  of  strong  fetor  it  is  practi- 
cal, however,  to  add  some  deodorizing  substance  like 
permanganate  of  potassium  (i :  looo)  or  formalin  (i  :  300), 
in  order  to  prevent  the  stench  from  clinging  to  the  basin 
and  utensils.  Peroxid  of  hydrogen,  a  fluid  often  recom- 
mended, possesses  no  advantage  over  any  other  deodor- 
izer. Its  alleged  power  to  dislodge  pus  by  the  bub- 
bles of  liberated  oxygen  is  a  myth.  After  syringing, 
boric  acid  powder  is  blown  in  in  a  thin  layer  with 
an  insufflator  (Fig.  21).  The  effect  of  this  treatment 
is  complete  removal  or  considerable  diminution  of 
the  odor  within  the  next  twenty-four  hours.  If  two, 
or,  at  the  most,  three  repetitions  of  this  treatment  at 
intervals  of  twenty-four  hours  do  not  remove  the  odor 
absolutely,  the  case  is  not  one  of  simple  suppuration 
without  retention,  and  the  further   continuance  of  this 


TREATMENT.  493 

form  of  treatment  is  totally  useless.  In  rare  cases  a 
single  thorough  application  stops  the  discharge  per- 
manently. More  commonly  from  one  to  two  and  a  half 
weeks  are  required  for  a  complete  cure.  The  discharge 
gets  less  copious  and  thinner  gradually.  If  the  treat- 
ment ceases  while  there  is  slight  discharge  left,  a  relapse 
is  very  probable.  If  the  intervals  between  treatments 
have  been  too  long,  the  time  required  for  a  cure  is  un- 
necessarily extended.  There  should  be  some  powder 
from  the  previous  application  found  in  the  meatus  at 
each  dressing.  Numerous  indorsements  of  substitutes 
for  boric  acid  have  generally  been  due  to  poor  observa- 
tion or  poor  reasoning.  In  those  instances  where  there 
is  no  retention  of  pus  the  healing  under  boric  acid  is  as 
rapid  as  the  nature  of  the  lesions  permits.  Boric  acid 
is  said  to  cause  eczema  of  the  meatus  in  rare  instances. 
This  I  have  never  seen.  There  are  some  cases,  however, 
in  which  it  starts  a  profuse  watery  discharge,  and  these 
patients  progress  more  rapidly  when  nothing  is  put  in 
the  meatus  after  syringing  except  a  sufficiently  large 
gauze  drain.  In  exceptional  instances  a  tedious  muco- 
purulent but  not  fetid  discharge  persists  long  in  spite  of 
treatment — probably  coming  from  the  Eustachian  tube. 
The  most  efficient  measure  I  have  found  in  such  cases 
to  be  the  instillation  of  tannin  dissolved  in  glycerin  (i  :  4). 

378.  After  the  cure  of  otitic  suppuration  the  hearing 
improves,  as  a  rule,  but  the  degree  of  improvement 
cannot  be  predicted.  The  hearing  can  be  noticeably 
augmented  in  some  patients  and  by  the  so-called  artifi- 
cial ear-drum.  This  acts  simply  as  a  support  for  the 
hammer,  and  is  of  use  only  in  some  instances  with 
moderate-sized  or  large  perforation.  A  pellet  of  cotton 
or  a  strip  of  gauze  fulfills  the  same  purpose.  When  the 
ear  has  become  permanently  dry,  the  Toynbee  artificial 
drum  of  rubber,  mounted  on  a  wire,  can  be  used  by  the 
patient  on  trial  (Fig.  138).  But,  after  all,  the  artificial 
drum  is  less  often  useful  than  the  public  believes. 

The   perforation   itself  persists   after  the  suppuration 


494 


CHRONIC    PURULENT    OTITIS. 


has  ceased.  An  effort  may  now  be  made  to  close  the 
hole,  according  to  the  method  of  OkunefF.  The  edges 
of  the  hole  are  touched  gently  with  trichloracetic  acid, 
by  saturating  a  thin  coating  of  cotton  around  a  probe 
with  the  deliquesced  acid.     There  is  usually  very  slight 


Fig.  137. — Cicatrix  in  the  puckered  and  thickened  membrana  tympani  after 
the  closure  of  a  perforation  due  to  a  severe  purulent  otitis.  The  cicatrix  appears 
dark  while  sunken  in ;  on  inflation  it  becomes  more  prominent  and  brighter. 

reaction  ;  sometimes,  however,  a  trifling  suppuration. 
After  all  reaction  has  ceased,  another  application  may  be 
made  if  the  hole  has  not  closed  entirely.  The  perfora- 
tion should  not  be  closed  if  there  is  any  reason  to  fear 
relapses. 

379.   Chronic  suppurative  otitis  with  retention  of  pus 


6 


Fig.  138. — Toynbee's  artificial 
drum  membrane,  consisting  of  a 
round  sheet  of  soft  rubber  with  a 
wire  handle. 


Fig.  139. — Perforation  in  Shrap- 
nell's  membrane  in  chronic  suppura- 
tion of  the  attic.  The  rest  of  the 
membrane  is  slightly  cloudy. 


may  present  the  same  appearances  as  the  simple  type  of  the 
disease  and  can  then  be  distinguished  only  by  the  failure 
of  the  therapeutic  test.  Generally,  however,  the  appear- 
ances are  different  and  indicate  involvement  of  the  attic. 
There  are  cases  in  which  the  membrana  proper  is  intact. 


PURULENT    OTITIS    WITH    RETENTION    OF    PUS. 


495 


and  where  there  is  only  a  small  perforation  in  Shrapnell's 
membrane.  In  others  Shrapnell's  membrane  is  largely 
destroyed  and  there  may  even  be  a  fissure  or  gap  in 
the  bone  around  Rivini's  incisure,  so  that  the  attic 
is  partly  exposed  to  view  (Figs.  139,  140 — compare  also 
Figs.  9  and  12,  Plate  II.).  Again,  the  upper  part  of 
the  membrane  may  be  intact,  but  there  is  a  large  hole 
or  even  total  deficiency  of  the  entire  lower  part,  with 
absence  of  the  handle  of  the  malleus  or  oblique  displace- 
ment of  its  stump  (Fig.  141).  Less  commonly  there  are 
two   perforations,  one   of  them    leading   into   the  attic. 


Fig.  140. — Chronic  suppuration 
from  the  attic  with  cholesteatoma; 
destruction  of  Shrapnell's  membrane 
and  of  the  superior  wall  of  the  mea- 
tus (anterior  wall  of  the  attic),  form- 
ing a  fissure  into  the  attic  in 
which  a  cholesteatomatous  globule  is 
lodged.  The  membrana  tympani 
proper  is  nearly  normal  and  only 
slightly  opaque. 


Fig.  141. — Chronic  purulent  otitis 
with  granulations  on  the  internal 
tympanic  wall.  Only  a  small  (upper) 
rim  of  the  drumhead  is  still  present. 
The  handle  of  the  hammer  is  partly 
destroyed,  and  the  remaining  stump 
is  adherent  to  the  inner  wall  of  the 
tympanic  cavity. 


The  criterion,  however,  is  not  so  much  the  appearances 
as  the  inability  to  deodorize  the  discharge.  When  two, 
or,  at  the  most,  three  thorough  efibrts  at  syringing, 
followed  by  boric  acid  insufflation,  have  failed  to  re- 
move the  odor,  incomplete  drainage  of  the  pus  must  be 
assumed,  even  though  the  discharge  may  have  been 
somewhat  lessened  by  the  treatment.  The  continuance 
of  this  treatment  will  then  prove  useless.  In  these  cases 
pus  is  formed  in  some  inaccessible  pocket  or  recess  in  the 
attic,  and  in  quite  a  number  of  instances  there  is  also 
suppuration  from  the   mastoid  antrum.     There  may  or 


496  CHRONIC    PURULENT    OTITIS    MEDIA. 

may  not  be  complications  in  the  way  of  caries  of  the 
osseous  walls  or  of  the  ossicles. 

380.  In  order  to  dislodge  the  pus  from  its  source  intra- 
tympanic  syringing  should  be  attempted  by  means  of  a 
fine  cannula  introduced  into  the  tympanic  cavity.  The 
Hartmann  cannula  of  hard  rubber  found  in  the  shops  is 
too  thick.  The  author  uses  a  thin  metallic  tube  closed 
at  the  end  with  a  lateral  eye  (Fig.  142).  The  stream  is 
directed  at  haphazard  toward  the  attic  and  toward  the 
mastoid  aditus.  The  tip  of  the  tube  follows  any  pre- 
existing fistulous  passage.  It  requires  a  steady  hand  if 
the  tube  is  attached  to  a  piston  syringe,  and  some  pain  is 
inevitable.     It  may,  however,  be  attached  by  means  of  a 


Fig.  142. — Blake's  syringe  for  the  middle  ear. 

flexible  tube  to  a.  syringe  which  an  assistant  manipulates. 
Sometimes  the  immediate  success  of  .this  mode  of  syring- 
ing is  assured  by  the  appearance  of  lumps  of  inspissated 
pus  of  foul  odor.  Another  mode  of  intratympanic  syr- 
inging recommended  by  German  surgeons  (Schwartze)  is 
through  the  Eustachian  tube  by  means  of  the  catheter. 
This  is  difficult  and  not  always  feasible.  It  is  easy,  how- 
ever, in  the  case  of  double-sided  disease  to  force  salt 
solution  through  the  Eustachian  tubes  by  means  of  a 
Politzer  bag  filled  with  the  fluid.  During  swallowing 
efforts  a  lively  stream  of  water  conies  from  the  ears.  I 
have  not  found  this  mode  of  syringing  efficient  as  often 
as  by  means  of  the  intratympanic  cannula. 


PERSISTENT   ODOR   OF    DISCHARGE.  497. 

When  these  measures  fail  to  deodorize,  success  can 
sometimes  be  obtained  by  filling  the  ears  with  a  fluid  of 
less  surface  tension  than  water.  A  mixture  of  alcohol 
and  ether  may  penetrate  into  crevices  inaccessible  to  the 
syringe.  It  is  especially  when  this  alcoholic  instillation 
is  followed  by  an  ear  bath  with  carbolated  glycerin  that 
an  occasional  success  is  obtained  in  deodorizing  the  dis- 
charge. As  soon  as  the  odor  has  been  removed,  the  case 
may  then  be  regarded  as  one  of  the  simple  type,  without 
retention,  and  will,  as  a  rule,  heal  under  the  previously 
described  treatment  The  healing,  however,  is  apt  to 
require  more  time. 

When  all  these  attempts  have  failed  to  remove  the 
fetor,  the  author  can  recommend  one  other  measure 
previous  to  surgical  intervention.  This  is  the  drainage 
of  the  secretion  by  capillary  absorption  through  a  gauze 
drain.  The  meatus  is  packed  with  a  sterile  strip  of 
gauze  placed  in  contact  with  the  drumhead,  or  even  the 
tympanic  lining,  and  replaced  by  another  before  it  has 
become  completely  soaked  by  the  discharge.  This 
method  introduced  in  the  treatment  of  chronic  purulent 
otitis  by  N.  Pierce  proves  successful  in  the  end  in  a 
number  of  instances  which  would  otherwise  be  incurable 
except  by  a  radical  operation.  The  action  of  the  gauze 
drain  is  peculiar.  The  discharge  is  often  increased 
slightly  at  first.  It  then  diminishes  gradually  without 
losing  its  offensive  odor  until  the  gauze  remains  dry. 
This  may  take  from  two  to  four  weeks,  or  longer  if  the 
treatment  has  not  been  carried  out  properly.  If  a  relapse 
occurs  after  the  odor  has  once  disappeared,  the  pus  is 
odorless.  The  various  measures  may  all  be  combined  in 
the  interest  of  the  patient.  There  is  no  objection  to 
beginning  with  gauze  drainage  at  the  first  treatment. 
Every  effort  possible,  however,  should  be  made  to  dis- 
lodge pent-up  pus  from  the  beginning.  For  as  soon  as 
deodorization  of  the  discharge  shows  success,  precious 
time  has  been  gained,  while  if  this  has  failed,  the  gauze 
drain  has  in  the  meantime  begun  its   influence.     Even 

32 


498  CHRONIC    PURULENT    OTITIS    MEDIA. 

after  the  stagnation  of  pus  has  been  obviated  these  cases 
may  prove  very  slow  in  healing.  But,  on  the  other 
hand,  it  is  no  great  hardship  to  a  patient  to  come  once  in 
four  or  six  days  for  a  fresh  packing,  even  though  some 
months  be  required.  When  the  gauze  is  left  in  the 
meatus  for  many  days  it  should  be  kept  aseptic  by 
powdering  it  freely  with  a  mixture  of  boric  and  salicylic 
acids.  The  longer  the  time  required  for  the  cure  of  the 
suppuration,  the  greater  the  probability  of  a  relapse  at 
some  future  time.  But  even  by  means  of  a  radical 
operation  we  cannot  give  these  patients  absolute  exemp- 
tion from  relapses,  and  in  the  meantime  we  can  at  least 
assure  them  that  they  are  free  from  danger  as  long  as  the 
ear  stays  dry,  and  practically  so  if  they  submit  to  treat- 
ment at  once  in  case  of  relapse. 

381.  When  it  proves  impossible  to  remove  the  odor,  or 
even  when  the  odorless  discharge  does  not  yield,  which 
is  very  exceptional,  we  must  decide  whether — {a)  to 
desist  and  wait,  {b)  remove  the  ossicles,  {c)  open  the 
antrum,  or  {d)  perform  a  radical  operation.  To  desist 
from  further  treatment  means  to  keep  the  patient  in 
constant  jeopardy  as  long  as  the  fetor  shows  stagnation 
of  pus.  If,  however,  efficient  drainage  is  proven  by  the 
absence  of  odor,  the  danger  of  waiting  indefinitely  while 
packing  the  ear  aseptically  is  probably  no  greater  than 
that  of  any  operation.  With  aseptic  packing  such  cases 
•will  generally  heal  in  the  end. 

The  removal  of  the  ossicles  (see  1  346)  cures  those 
instances  in  which  pus  stagnates  in  the  pockets  and 
recesses  of  the  attic,  and  especially  those  in  which  the 
ossicles  themselves  are  carious  (1"  385).  A  small  perfora- 
tion in  Shrapnell's  membrane  is  strongly  suggestive, 
though  not  proof  positive,  of  caries  of  the  anvil  or 
hammer  or  both.  A  larger  destruction  of  the  flaccid 
membrane,  especially  if  it  extends  to  the  periphery, 
points  to  caries  of  the  walls  of  the  attic.  We  cannot 
foretell,  however,  in  any  such  case  whether  the  mastoid 
antrum   is   involved   or  not,    and   hence  ossiculectomy, 


RADICAL   OPERATION.  499 

while  usually  beneficial,  is  not  always  curative.  When 
the  pus  is  abundant  we  can  almost  surely  expect  disease 
of  the  antrum.  The  operation  of  ossiculectomy  is  free 
from  serious  danger  in  the  hands  of  the  expert.  If  the 
stapes  is  accidentally  dislocated,  distressing  dizziness  may 
follow  for  many  days.  Ossiculectomy  rarely  injures  the 
remaining  hearing  power,  but  often  improves  it  to  a 
moderate  extent.  The  operation  is  usually  too  painful 
without  general  narcosis  in  purulent  cases.  In  the  case 
of  a  narrow  meatus  it  cannot  be  done  without  temporary 
resection  of  the  cartilaginous  portion.  This  makes  a 
larger  operation,  and  in  such  cases  it  is  better  to  do  the 
radical  operation  at  once. 

382.  Opening  the  mastoid  (1  370)  cures  the  majority 
of  cases  of  otherwise  incurable  suppuration  of  the  attic 
and  antrum.  In  these  chronic  instances,  however,  the 
after-treatment  is  sometimes  very  tedious  and  protracted 
through  months.  It  should  be  the  preferred  operation 
in  those  instances  in  which  the  persistence  of  good  hear- 
ing makes  it  desirable  to  save  the  ossicles.  It  may  also 
be  done  when  the  ossicles  have  been  entirely  destroyed 
previously  by  disease.  Simply  opening  the  mastoid  is, 
however,  not  so  sure  of  success  as  the  radical  operation, 
but,  on  the  other  hand,  easier  and  perhaps  a  trifle  safer. 
After  establishing  a  large  opening  into  the  antrum,  both 
this  artificial  canal  and  the  meatus  should  be  kept  packed 
until  all  discharge  has  ceased.  This  may  take  from  one 
to  four  months.  In  old  chronic  purulent  otitis  the  mas- 
toid is  often  found  sclerotic,  probably  as  the  consequence 
of  long-continued  suppuration.  It  is  hence  usually  more 
difficult  to  chisel  into  the  antrum  than  in  the  case  of 
fresh  disease. 

383.  The  radical  operation  is  intended  to  convert  the 
tympanic  cavity,  the  attic,  and  the  mastoid  antrum  into 
one  large  continuous  cavity  with  unobstructed  outlet.  It 
should  be  done  in  all  cases  of  inaccessible  cholesteatoma 
or  of  chronic  fetid  suppuration  otherwise  incurable,  espe- 
cially, however,  when  urgent  danger  symptoms  are  pres- 


500  CHRONIC    PURULENT    OTITIS    MEDIA. 

ent.  Of  the  various  modifications  of  the  radical  opera- 
tion, I  will  describe  the  one  suggested  by  Zaufal  as  the 
easiest  (compare  mastoid  operation,  1  370). 

General  narcosis.     Detachment  of  the  auricle  and  of 
the  cartilaginous  part  of  the  meatus  by  a  long,  slightly 


Fig.  143. — The  radical  operation  completed.  Antrum  and  attic  fully  ex- 
posed and  the  two  ossicles  removed.  Of  the  internal  portion  of  the  posterior 
wall  of  the  meatus  a  slanting  ridge  is  left  intact  in  order  to  protect  the  canal 
of  the  facial  nerve. 

curved  incision  down  to  the  bone  from  above  the  upper 
rim  of  the  auricle  to  a  point  below  the  tip  of  the  lobule, 
I  cm.  behind  the  insertion  of  the  auricle.  Elevation  of 
the  periosteum  backward  and  forward  from  the  incision 


RADICAL   OPERATION.  5OI 

up  to  the  cartilaginous  meatus.  Detachment  of  the  lat- 
ter from  the  rear,  and  transverse  (vertical)  incision  with 
a  tenotome  through  the  posterior  upper  cutaneous  wall 
of  the  bony  meatus  as  far  inward  as  possible.  The  par- 
tially detached  cartilaginous  meatus  is  pulled  forward 
by  the  steady  action  of  a  small  retractor  placed  in  the 
meatus.  The  mastoid  surface  is  now  attacked  by  the 
chisel  in  the  usual  place — viz.,  immediately  behind  the 
meatus  and  a  trifle  above  its  center.  But  instead  of 
merely  making  a  funnel-shaped  hole  in  the  mastoid 
process,  the  chisel  is  directed  against  the  meatus  so  that 
its  upper  posterior  wall  is  gradually  removed.  The 
wound  in  the  bone  assumes  thus  the  shape  of  a  broad 
crater,  the  inferior  and  anterior  boundaries  of  which  are 
the  normal  inferior  and  anterior  walls  of  the  meatus.  As 
soon  as  the  antrum  is  reached  any  bleeding  granulations 
are  curetted. 

While  at  the  external  orifice  of  the  wound  in  the 
bone  the  posterior  wall  of  the  meatus  should  be  en- 
tirely removed,  the  lower  part  of  the  posterior  wall 
must  be  scrupulously  avoided  as  the  surgeon  approaches 
the  tympanic  cavity  (Fig.  143),  for  otherwise  the  facial 
nerve  and  possibly  the  external  semicircular  canal  would 
be  wounded.  The  internal  portion  of  the  posterior  wall 
of  the  meatus  hence  forms  a  slanting  ridge  along  the 
floor  of  the  cavity  thus  created.  After  the  antrum  is 
reached,  small  chisels  are  carefully  used  to  cut  away  the 
external  wall  of  the  tympanic  attic  (upper  wall  of  the 
meatus),  so  as  to  gain  access  to  the  entire  tympanic  space, 
until  a  curved  probe  meets  with  no  obstacle  in  gliding 
outward  from  the  roof  of  the  attic  along  the  upper  (partly 
resected)  wall  of  the  meatus.  During  this  part  of  the 
operation  Stacke's  guard  (Fig.  144)  may  be  used  to  pro- 
tect the  internal  wall  of  the  drum  cavity  (labyrinth  and 
facial  nerve)  against  accidental  slipping  of  the  chisel. 
The  guard  is  held  by  an  assistant  after  introduction  into 
the  drum  cavity.  The  patient's  face  should  be  watched 
continuously  by  the  assistant,  in  order  to  call  attention 


502  CHRONIC    PURULENT    OTITIS    MEDIA. 

to  any  twitching  of  the  facial  muscles  indicative  of  irri- 
tation of  the  facial  nerve.  Whenever  feasible,  delicate 
bone  nippers  may  be  used  from  the  antrum  forward  to 
remove  the  bone  in  fragments.  Finally  the  entire  tym- 
panic space,  including  its  attic,  becomes  accessible,  and 
on  account  of  the  previous  removal  of  the  cartilaginous 
meatus  it  can  be  well  inspected  with  good  illumination 
without  head  mirror.  The  two  ossicles  are  now  removed 
with  forceps  after  severing  their  adhesions  with  small 
knives.  Wherever  granulations  are  found  they  are 
curetted  off  under  the  guidance  of  the  eye  from  within 
outward.  Curetting  blindly  is  too  dangerous.  The 
stapes   should   not   be    touched    unless   found   denuded. 

|lllii!!;;:l,,,|, «iii"'!'i^^i^^^Slli!iifll!!l!!llill 


Fig.  144. — Stacke's  guard  for  the  protection  of  the  facial  canal  and  labyrinthine 
wall  in  the  radical  operation. 

After  the  removal  of  all  diseased  tissue  the  posterior 
membranous  wall  of  the  meatus  is  slit  longitudinally 
from  without  inward,  so  that  the  two  flaps  can  apply 
themselves  to  the  posterior  upper  bony  surface  of  the 
surgical  channel. 

In  case  of  cholesteatoma,  or  when  it  has  been  found 
impossible  to  remove  all  diseased  tissue  with  certainty, 
or  in  case  of  dangerous  symptoms,  the  retro-auricular 
opening  is  left  open  and  drained.  Otherwise  it  may 
be  closed  by  sutures  and  the  after-treatment  carried 
out  through  the  meatus.  Very  careful  packing  with 
gauze  is  essential.  The  directions  for  changing  the 
gauze  are  the  same  as  in  the  case  of  the  ordinary 
mastoid   operation.       During  subsequent   dressings   any 


RADICAL    OPERATION.  503 

adhesion  of  the  gauze  strips  in  the  depth  of  the 
wound  can  be  overcome  in  the  gentlest  manner  by  in- 
stilling peroxid  of  hydrogen  solution.  The  cicatriza- 
tion of  the  extensive  cavity  may  be  materially  hastened 
by  placing  Thiersch  grafts  upon  the  exposed  bone,  either 
at  the  end  of  the  operation  or  as  soon  as  satisfactory 
cicatrization  is  in  progress.  Still  it  never  takes  less 
than  three  to  four  weeks,  and  not  rarely  as  many  months, 
before  cicatrization  is  complete  and  all  discharge  has 
ceased.  Considerable  care  is  required  during  the  after- 
treatment.  Excessive  granulations  must  be  curetted  or 
touched  with  nitrate  of  silver.  Careful  packing  is  in- 
dispensable up  to  the  end.  After  the  discharge  has 
ceased  the  patient  should  stay  under  observation  for 
many  weeks  with  periodic  inflations  of  boric  acid. 

A  properly  done  radical  operation  is  absolutely  cura- 
tive, but  it  is  not  always  possible  to  remove  all  diseased 
bone  at  once.  The  loss  of  the  odor  indicates  whether  the 
operation  has  been  thorough  or  not.  Even  when  some 
odor  persists  it  will  now  yield  gradually  to  packing.  No 
radical  operation,  however,  can  give  an  absolute  guar- 
antee against  a  future  relapse  of  suppuration.  But  with 
all  obstacles  to  drainage  removed,  and  nothing  left  but  a 
clear  space,  such  relapses  are  not  likely  to  prove  serious 
or  rebellious  to  very  simple  treatment.  The  radical 
operation  does  not  often  injure  what  hearing  there  is  left, 
and,  indeed,  may  improve  it  moderately.  Injury  to  the 
facial  nerve,  a  deplorable  accident,  has  happened  occa- 
sionally in  operations  done  by  expert  surgeons. 

The  form  of  radical  operation  described  above  is  the  one  sug- 
gested by  Zaufal,  which  I  personally  consider  the  easiest  and 
safest  for  the  less  experienced  operator.  Nearly  at  the  same 
time  Kuester,  Zaufal,  and  Stacke  (1889  to  1890)  advocated  a  more 
radical  operation  than  the  mere  opening  of  the  mastoid  in  chronic 
cases,  by  removing  at  the  same  time  the  posterior  wall  of  the 
meatus  and  the  external  wall  of  the  attic.  Stacke' s  operation  is 
primarily  intended  for  the  removal  of  the  ossicles..  The  auricle 
and  cartilaginous  meatus  are  detached,  and  the  superior  wall  of 
the  meatus  is  chiseled  off  until  no  barrier  is  left  in  front  of  the 


504  CHRONIC    PURULENT    OTITIS    MEDIA. 

attic.  After  cleaning  the  attic  the  mastoid  cavity  is  explored 
through  its  aditus,  and  if  found  diseased  is  opened  by  chiseling 
away  the  posterior  wall  of  the  meatus.  Most  surgeons,  especially 
in  this  country,  prefer  to  remove  the  ossicles  through  the  intact 
meatus  when  the  anatomic  conditions  are  favorable.  Hence 
Stacke's  operation,  as  mostly  done,  is  really  a  radical  operation 
with  slightly  modified  technic. 

A  number  of  modifications  have  been  devised  in  the 
plastic  part  of  the  operation,  in  order  to  cover  the  exposed 
bony  surface.  Among  the  most  serviceable  plans  is  that 
of  Siebenmann.  He  does  not  keep  the  retro-auricular 
opening  patent  as  such,  but  combines  its  orifice  with  the 
meatus  by  using  the  skin  of  the  concha  as  a  lining.  The 
detached  meatus  is  slit  longitudinally  in  the  center  of  its 
posterior  wall,  and  from  the  external  end  of  this  slit  a  cut 
is  made  downward  and  another  upward  through  the 
concha,  so  that  the  entire  incision  has  the  shape  of  a  hori- 
zontal Y.  The  cartilage  is  thereupon  resected  from  the 
posterior  surface  of  these  flaps,  so  that  they  can  be  com- 
pletely adapted  to  the  exposed  bony  surface  of  the  wound, 
being  held  in  place  by  tamponing. 

As  far  as  the  bony  surface  is  surely  healthy  it  may  be 
covered  with  Thiersch  grafts  at  the  time  of  the  operation, 
which  are  kept  in  place  by  the  tampon.  In  the  deeper 
parts  of  the  wound  grafts  should  be  used  only  after  longer 
observation  has  shown  normal  healing  without  the  pres- 
ence of  any  bone  disease  or  focus  of  suppuration. 


CHAPTER    XLIII. 

LOCAL    COMPLICATIONS   OF  CHRONIC    PURULENT 

OTITIS. 

POLYPI.  — CARIES   AND   NECROSIS   OF   THE    BONE.  — CHO- 

LESTEATOMA.-PARALYSIS  OF  THE  FACIAL  NERVE 

TUBERCULAR  OTITIS. 

384.  Polypi  are  a  frequent  occurrence  in  chronic  otitic 
suppuration.  Granulation  tissue  in  the  form  of  red,  ele- 
vated, easily  bleeding  patches  is  often  seen  in  the  tym- 
panic cavity  through  perforations.  When  this  occurs  in 
the  form  of  a  tumor  with  a  constricted  pedicle,  it  forms  a 
polypus.  Polypi  are  made  up  of  granulation  tissue  origi- 
nally, but  many  in  the  course  of  time  assume  a  firmer 
consistency  by  fibrillary  transformation.  They  are  lined 
with  epithelium  and  are  quite  vascular.  They  may 
resemble  minute  beads,  being  sometimes  multiple,  or  may 
grow  until  a  large  reddish  mass  fills  the  whole  meatus 


Fig,  145. — A  lobulated  polypus  springing  from  the  upper  part  of  the  tym- 
panic cavity  and  protruding  through  a  large  perforation  in  the  upper  posterior 
quadrant  of  the  drumhead.  The  membrana  tympani  is  thickened  so  that  the 
manubrium  is  not  visible. 

(Fig.  145).  They  originate  mostly  from  the  attic  ;  rarely 
from  a  carious  spot  in  the  wall  of  the  meatus.  They  are 
often,  but  perhaps  not  always,  indicative  of  caries  under- 
neath. When  cut  off  incompletely,  they  are  apt  to  grow 
again.  Their  removal  should  hence  be  thorough.  Co- 
cain  and  suprarenal   solution   make   general   anesthesia 

505 


506    LOCAL    COMPLICATIONS    OF    CHRONIC    PURULENT    OTITIS. 

superfluous.  The  most  satisfactory  instrument  is  a  deli- 
cate snare  (Fig.  146),  the  loop  of  which  grasps  the  growth 
next  to  its  base.  The  best  wire  is  the  thin  flexible  iron 
wire  used  by  florists.  The  base  should  then  be  curetted. 
Cauterization  is  generally  superfluous,  except  when  the 
base  is  inaccessible  to  the  curet  in  the  attic.  A  suitably 
bent  probe  upon  which  a  bead  of  chromic  acid  has 
been  melted  can  then  follow  the  path  of  the  polypus 
to  its  base.     The  excess  of  the  acid  is  removed  by  a  solu- 


c»= 


Fig.  146. — Blake's  polypus  snare. 

tion  of  bicarbonate  of  sodium.  It  is  worth  remembering 
that  small  polypi  may  disappear  without  operation  under 
boric  acid  insuflBation,  provided  there  is  no  stagnation 
of  pus. 

385.  Bone  disease  is  a  frequent  complication  and 
often  the  cause  of  the  persistence  of  chronic  otitis,  espe- 
cially in  poorly  nourished  subjects.  Relatively  rare  in  the 
simple  form, -it  is  very  common  when  there  is  stagnation 
of  pus.  The  more  usual  form  of  the  disease  is  caries,  while 
the  necrotic  separation  of  a  sequestrum  is  much  less 
common.  The  most  frequent  seat  of  caries  is  in  the 
ossicles,  especially  the  long  process  of  the  anvil  ;  less  fre- 
quently the  head  of  the  anvil  or  the  head  of  the  hammer. 
The  destruction  of  bone  is  not  a  passive  corrosion  by  pus, 
but  a  true  ostitic  ulceration.  Caries  of  the  head  of  the 
hammer  is  indicated  usually  by  a  fistula  in  Shrapnell's 
membrane.  Destruction  of  the  anvil  may  be  suspected 
when  the  greater  part  of  the  membrana  tympani  is  de- 
stroyed, or  in  case  of  perforation  at  its  upper  rear  border. 
Less  commonly  than  in  the  ossicles  caries  is  found  in 
some  area  of  the  tympanic  wall  ;  sometimes  even  in  the 


BONE    DISEASE.  507 

meatus.  A  noticeable  seat  of  the  disease  is  the  bony  mar- 
gin around  Shrapnell's  membrane,  where  large  bony 
defects  are  not  infrequently  met  with.  There  are  no 
symptoms  attributable  to  caries  in  these  localities  beyond 
the  persistence  of  the  discharge.  Whether  the  fetor  of 
the  discharge  can  be  abolished  or  not  depends  on  the  con- 
ditions for  drainage  and  not  on  the  presence  of  the  bone 
disease.  The  diagnosis  can  be  assured  only  by  feeling 
the  exposed  bone  with  a  delicate  probe.  Granulation 
tissue  and  polypi  render  the  existence  of  caries  underneath 
probable. 

The  treatment  in  these  instances  is  that  of  the  chronic 
otitis.  After  drainage  has  been  established  as  indicated 
by  the  absence  of  fetor,  carious  spots  will  generally  heal. 
When  an  odorless  slight  discharge  proves  rebellious  to 
treatment,  various  devices  may  be  used  with  more  or  less 
uncertain  result.  Instillations  of  a  4  per  cent,  solution 
of  hydrochloric  acid  left  in  for  some  fifteen  minutes  or 
kept  in  for  a  day  on  a  pledget  of  cotton,  can  dissolve  dead 
bone  and  facilitate  cicatrization,  but  the  effect  is  uncer- 
tain. A  solution  of  iodoform  in  alcohol  and  ether  has 
proved  a  little  more  definite  in  its  action.  A  few  times 
I  have  seen  unquestionable  results  from  the  use  of  balsam 
of  Peru,  followed  by  the  ordinary  aseptic  packing. 

Caries  in  the  mastoid  antrum  is  incurable  as  far  as  we 
know,  except  by  proper  opening  of  the  antrum.  In  the 
antrum  necrotic  sequestra  are  found  oftener  than  in  other 
parts  of  the  ear. 

When  progressive  caries  extends  inward  into  the 
petrous  bone,  it  may  lead  to  serious  symptoms.  Carious 
spots  have  been  found  relatively  often  in  the  bony  walls 
of  the  semicircular  canals,  especially  the  horizontal  canal. 
This  localization  is  characteristically  indicated  by  persis- 
tent dizziness.  Headache  and  local  pain  mayor  may  not 
be  present.  When  present,  however,  these  sensory  symp- 
toms constitute  an  important  warning.  A  small  number 
of  instances  have  been  observed  in  which  necrosis  ex- 
tended into  the  petrous  pyramid  and  the  entire  cochlea 


508    LOCAL    COMPLICATIONS    OF    CHRONIC    PURULENT    OTITIS. 

has  been  extruded  by  spontaneous  demarcation  a  number 
of  times  with  ultimate  recovery.  Whenever  urgent 
symptoms — dizziness,  pain,  headache,  especially  with 
fetor  of  the  discharge — indicate  progressive  caries,  noth- 
ing can  be  considered  except  a  radical  operation.  In  all 
instances  of  caries  the  general  health  should  receive  due 
attention,  and  no  details  of  hygienic  management — fresh 
air,  exercise — or  therapeutic  indications — iron,  cod-liver 
oil,  or  whatever  may  be  required — should  be  overlooked. 

386.  Cholesteatoma  is  the  most  serious  of  all  local 
complications  of  chronic  otitis.  This  name  is  given  to 
concretions  of  exfoliated  epidermis  gathering  in  the 
aural  spaces  during  or  after  a  chronic  suppurative  proc- 
ess. The  desquamative  inflammation  limited  to  the 
meatus  has  been  described  under  the  head  of  epidermis 
plugs  (T[  325).  Oftener  than  in  the  meatus  it  is  found  in 
the  attic  of  the  middle  ear  and  in  the  mastoid  antrum. 
The  masses  are  white  or  yellowish,  distinctly  laminated, 
sometimes  of  firm  consistency,  and  rounded  like  a  pearl; 
at  other  times  more  friable  and  conform  with  the  shape 
of  the  space.  The  masses  consist  of  epidermis  scales 
with  cholesterin  crystals  and  more  or  less  inspissated  pus. 
When  there  is  suppuration,  there  is  always  decomposition 
of  fluids  around  and  in  the  cholesteatoma.  But  after  the 
suppuration  has  ceased  there  may  be  no  fetor  whatsoever. 
Even  bland,  odorless  cholesteatomata  may  continue  to 
grow  and  enlarge  the  bony  space  in  which  they  are 
confined.  The  formation  of  these  masses  is  due  to  des- 
quamation of  cutaneous  epithelium  derived  from  the 
meatus,  which  has  grown  through  a  peripheral  perfora- 
tion in  the  drumhead  into  the  middle  ear  or  attic,  or  even 
into  the  mastoid  antrum.  This  comprehensive  statement 
defines  the  conditions  under  which  cholesteatomatous  con- 
cretions grow.  Why  this  desquamation  takes  place  is 
not  fully  known.  It  may  continue  to  take  place  even 
after  suppuration  has  ceased. 

The  diagnosis  of  cholesteatoma  is  obvious  when  the 
mass  is  seen  either  limited  to  the  meatus,  or  protruding 


CHOLESTEATOMA.  5O9 

into  the  same,  or  when  visible  in  the  attic  on  account  of 
the  existence  of  a  defect  in  the  bone  at  the  upper  margin 
of  the  drumhead.  (Comp.  Fig.  12,  Plate  II.)  When  the 
cholesteatoma  is  not  visible,  its  presence  may  be  inferred 
by  the  persistent  appearance  of  epidermis  scales  in  the 
fluid  on  irrigating  the  middle  ear.  Inspection  must 
decide,  however,  whether  these  scales  are  not  simply 
derived  from  the  macerated  walls  of  the  meatus.  Choles- 
teatoma confined  to  the  antrum  may  not  make  its  pres- 
ence known  until  the  cavity  is  opened  by  an  operation. 

When  a  cholesteatomatous  formation  coexists  with 
fetid  suppuration,  the  latter  cannot  be  influenced  until 
the  epidermis  masses  are  removed.  This  is  possible  only 
if  they  are  accessible  to  the  eye  or  to  the  intratympanic 
cannula,  but  not  if  they  extend  into  the  antrum.  When 
the  otitic  suppuration  has  been  cured,  the  masses  may 
form  again  in  the  course  of  months  without  producing 
symptoms.  Sooner  or  later  relapse  of  suppuration  will 
follow.  As  a  rule,  this  can  again  be  cured  by  the  com- 
plete removal  of  the  cholesteatoma.  In  those  instances 
in  which  past  experience  has  shown  that  the  suppuration 
can  be  easily  deodorized  and  controlled  the  patient  is 
in  no  greater  danger  when  treated  conservatively  and 
watched  than  when  subjected  to  the  radical  operation, 
especially  as  the  latter,  too,  gives  no  absolute  guarantee 
against  relapse.  If,  however,  the  discharge  cannot  be 
deodorized,  a  cholesteatoma  demands  radical  operation 
without  question.  There  are  obscure  cases  in  which 
cholesteatoma  of  the  mastoid  antrum  without  suppura- 
tion causes  persistent  dull  feeling,  discomfort,  pain,  and 
threatens  life  by  the  possibility  of  pyogenic  complication 
with  extension.  A  presumptive  diagnosis  of  such  cases 
is  based  on  the  history  of  former  long-continued  suppura- 
tion and  the  existence  of  peripheral  defects  in  the  drum- 
head. 

387.  Since  the  facial  nerve  is  separated  from  the  tym- 
panic cavity  only  by  the  thin  walls  of  the  Fallopian 
canal,   which  may  even  be  defective,  it  is  evident  that 


5IO    LOCAL    COMPLICATIONS    OF    CHRONIC    PURULENT    OTITIS. 

facial  paralysis  may  occur  in  consequence  of  middle-ear 
disease.  This  is  rare  in  the  course  of  an  acute  catarrhal 
otitis,  and  not  common  in  acute  suppurative  inflamma- 
tion, but  by  no  means  rare  when  persisting  suppuration 
has  led  to  caries.  Facial  paralysis  is  more  often  due, 
however,  to  traumatism,  rarely  from  the  simple  mastoid 
operation,  oftener  from  a  radical  operation  even  by  an 
experienced  surgeon.  It  may  likewise  result  from 
violence  in  the  extraction  of  a  foreign  body.  The  symp- 
toms are  the  well-known  palsy  of  the  facial  muscles  on 
the  same  side.  In  the  case  of  a  paralysis  due  to  an 
inflammatory  process  recovery  may  follow  in  three  to  six 
weeks.  Severe  traumatism  may  protract  the  regeneration 
until  after  the  lapse  of  four  months  or  may  make  it  im- 
possible. It  is  an  open  question  among  neurologists 
whether  the  local  use  of  electricity  in  any  form  has  a 
permanent  influence.  When  the  paralysis  is  due  to  an 
inflammatory  process,  improved  drainage,  if  necessary  by 
means  of  a  mastoid  operation,  is  indicated.  In  all  opera- 
tions involving  the  posterior  wall  of  the  meatus  the  part 
adjoining  the  drumhead  should  be  scrupulously  avoided 
on  account  of  its  proximity  to  the  Fallopian  canal.  The 
latter  is  not  endangered  by  the  removal  of  the  upper 
wall  of  the  meatus.  The  chorda  tympani  nerve  is  easily 
wounded  by  intratympanic  manipulations ;  necessarily 
so  during  removal  of  the  ossicles.  Its  division  causes 
loss  of  taste  in  the  tip  of  the  tongue  with  a  numb 
feeling. 

388.  Tuberculosis  of  the  middle  ear  is  not  a  frequent 
disease,  but  common  enough  to  deserve  attention.  It  is 
probably  always  secondary  and  usually  occurs  only  in 
pronouncedly  tubercular  subjects.  The  process  may 
begin  in  the  tympanic  mucous  membrane,  but  is  almost 
sure  to  invade  the  bone  sooner  or  later.  Tubercular 
otitis  is  characterized  by  the  absence  of  acute  symptoms, 
even  if  of  acute  onset.  Pain  is  conspicuously  absent. 
There  may  be  a  feeling  of  fulness  for  a  few  days,  where- 
upon  perforation   occurs   and   a   seropurulent  discharge 


TUBERCULOSIS.  5  1 1 

begins.  In  some  instances  tuberculosis  of  the  middle 
ear  leads  to  abundant  granulations  filling  the  entire  cav- 
ity. In  others  a  fibrinous  pseudomembrane  adheres  to 
the  diseased  surface.  In  either  case  there  is  remarkably- 
little  irritation.  In  advanced  tuberculosis  of  the  system 
the  drumhead  and  bony  walls  may  break  down  very 
rapidly  with  scarcely  any  granulation  tissue.  The  diag- 
nosis suggested  by  the  tubercular  history  and  the  peculiar 
onset  should  be  verified  by  searching  for  the  tubercle 
bacillus  in  the  discharge  by  means  of  the  usual  staining 
methods.  The  bacilli  are  sometimes  scant  in  number, 
and  may  be  found  only  after  repeated  examination. 

Under  favorable  environment  and  proper  local  treat- 
ment the  disease  may  come  to  a  stand-still  or  even  end  in 
recovery.  The  local  treatment  is  the  same  as  in  other 
forms  of  otitic  suppuration.  When  destruction  of  bone 
has  occurred,  a  radical  operation  should  be  performed  if 
the  general  health  warrants  it.  In  properly  selected 
cases  it  arrests  the  local  disease  permanently.  Of  course, 
all  hygienic  measures  proper  in  tuberculosis  should  be 
carried  out. 


CHAPTER   XLIV. 
OTALGIA. 

389.  The  name  otalgia  is  given  to  the  various  forms 
of  pain  referred  to  the  ear  which  cannot  be  traced 
directly  to  some  aural  lesion.  It  is  hence  the  generic 
name  of  pain  which  may  vary  much  in  character  and 
duration.  The  complaint  may  be  a  trivial  one;  or,  in 
other  cases,  it  may  incapacitate  the  suflferer.  It  is  mostly 
one-sided. 

Some  instances  of  otalgia  can  be  definitely  traced  to  a 
dental  origin — sometimes  the  eruption  of  a  wisdom- 
tooth,  oftener  caries  of  a  molar  tooth,  either  upper  or 
lower.  In  the  former  case  the  pain  ceases  when  the 
tooth  has  made  its  appearance,  unless  some  soreness  of 
the  gum  persists.  In  the  case  of  a  carious  tooth  the  pain 
may  persist  until  the  origin  is  recognized  and  remedied. 
There  may  not  be  any  toothache  whatsoever.  Some- 
times the  pain  is  intermittent.  In  an  extreme  instance 
observed  by  myself  a  young  child  had  had  daily  attacks 
of  earache  for  some  months.  After  passing  through  the 
hands  of  half  a  dozen  physicians  without  relief,  the  child 
had  become  accustomed  to  daily  injections  of  morphin. 
The  attacks  ceased  at  once  after  extracting  a  carious 
tooth. 

In  other  instances  the  pain  referred  to  the  ear  is  of 
pharyngeal  origin.  Acute  inflammations  in  the  lateral 
angle  of  the  pharynx,  ulcerations  of  any  kind,  tonsillar 
wounds,  carcinoma  of  the  faucial  or  lingual  tonsil,  are 
all  apt  to  be  accompanied  by  more  or  less  earache.  But 
when  such  lesions  can  be  demonstrated,  the  term  otalgia 
is  superfluous.  In  hysteric  subjects  painful  affections  of 
the  throat  sometimes  leave  behind  a  psychic  remembrance 
of  the  pain  referred  to  the  ear,  even  long  after  the  heal- 

512 


OTALGIA.  513 

ing  of  the  original  lesion.  It  is  very  difficult  to  relieve 
such  patients.  Their  pain  usually  yields  to  nothing  but 
time,  or  some  strongly  impressive  suggestive  treatment. 
The  use  of  electricity  may  come  under  this  head.  Severe 
pain,  constant  or  intermittent,  referred  to  the  mastoid 
region  without  evidence  of  existing  ear  disease,  is  in  rare 
cases  due  to  a  growing  cholesteatoma  without  suppura- 
tion, or  may  even  indicate  a  subdural  abscess.  The 
diagnosis  is  suggested  in  such  cases  by  the  former  his- 
tory of  otitic  suppuration.  There  are  on  record  some 
instances  in  which  persistent  pain,  uncontrollable  by 
other  means,  led  to  an  attempt  at  mastoid  operation. 
The  bone  was  found  sclerotic.  The  antrum  was  either 
not  reached  or  found  intact,  and  still  the  operation,  ap- 
parently uncalled  for,  resulted  in  a  permanent  cure. 

In  the  majority  of  cases  of  so-called  otalgia  no  local  cause 
can  be  found.  Sometimes  the  attacks  are  typically  neural- 
gic and  may  yield  to  antipyrin,  quinin,  or  arsenic.  Regu- 
lar periodicity  of  the  pain  has  in  a  few  instances  been 
traced  to  malarial  influence  and  cured  by  quinin.  In 
other  cases  again  the  pain  is  not  typical  of  neuralgia. 
It  may  depend  on  anemia,  and  in  such  instances  is 
benefited  by  iron.  If  it  is  in  any  way  related  to  rheu- 
matism, large  doses  of  salicylate  of  sodium  may  some- 
times prove  of  benefit.  One  of  the  rarest  forms  of 
otalgia,  usually  bilateral,  is  periodic  migraine  localized 
in  and  limited  to  the  region  of  the  ear.  Its  diagnosis  is 
made  by  its  irregular  periodicity  and  its  accompanying 
symptoms — for  instance,  the  more  characteristic  sick 
headache  or  nausea. 
33 


CHAPTER  XLV. 

PYOGENIC    EXTENSION   OF   OTITIS. 

SEROUS    AND    PURULENT    MENINGITIS PHLEBITIS    AND 

THROMBOSIS  OF  THE  LATERAL  SINUS  WITH  SEPTI- 
CEMIA OR  PYEMIA.— SUBDURAL  ABSCESS.— ABSCESS 
OF  THE  BRAIN. 

390.  The  greatest  danger  of  otitic  suppuration,  acute 
or  chronic,  is  the  possibility  of  its  extension  into  the  cra- 
nial cavity.  This  may  take  place  through  the  intact  roof 
of  the  middle  ear  or  of  the  mastoid  antrum,  when  the  plate 
of  bone  is  thin  or  ev^en  partially  deficient.  In  children  the 
relatively  thick  roof  of  the  mastoid  antrum  diminishes  the 
danger  from  this  locality.  Oftener,  however,  carious  spots 
and  fistulae  are  found  in  the  roof  of  tympanum  or  antrum. 
In  the  antrum  the  inflammatory  process  may  extend 
through  connecting  pneumatic  cells  to  the  cranial  sur- 
face. Less  common  is  suppurative  extension  into  the 
labyrinth,  whence  it  can  reach  the  cranial  cavity  either 
through  the  aqueducts  or  along  the  course  of  the  audi- 
tory nerve.  Quite  rare  is  the  propagation  of  the  disease 
through  a  thin  anterior  wall  of  the  tympanic  cavity  to  the 
carotid  canal  and  thence  upward. 

The  diagnosis  of  intracranial  complications  may  be 
quite  difficult,  especially  the  differential  diagnosis  be- 
tween the  different  lesions.  With  the  exception  of 
meningitis  the  other  complications  may  sometimes  de- 
velop so  gradually  as  to  mislead  any  one  not  thoroughly 
familiar  with  the  symptomatology  of  inflammator\^  ear 
disease.  On  the  other  hand,  an  otitis  may  itself  provoke 
symptoms  which  suggest  a  cerebral  complication.  As 
pointed  out  in  T[  358,  acute  otitis  produces  occasionally 
in  children — very  rarely  in  adults — symptoms  which 
simulate  brain  disease — viz.,  headache,  stupor,  delirium, 

514 


SEROUS    AND    PURULENT    MENINGITIS.  515 

or  convulsions.  The  dependence  of  these  symptoms  on 
the  inflammation  of  the  middle  ear  may  be  shown  by 
their  prompt  cessation  after  paracentesis  of  the  drum- 
head, but  such  observations  are  very  rare.  The  per- 
sistence of  such  symptoms,  except  headache,  after  free 
drainage  has  been  established  would  positively  indicate 
extension  beyond  the  tympanic  cavity. 

In  chronic  cases  with  cholesteatoma  or  caries  it  may 
also  be  difficult  to  recognize  intracranial  complications 
at  the  beginning.  One-sided  headache,  dizziness,  nausea, 
and  vomiting  may  depend  merely  on  extension  of  the 
disease  into  the  labyrinth,  or  may  signal  the  beginning 
of  an  intracranial  accident.  Fever  is  a  more  significant 
symptom.  It  is  only  moderate  and  transient  in  uncom- 
plicated acute  otitis,  except  in  children.  If,  therefore,  a 
high  fever  persists  during  acute  aural  disease,  or  still 
more  significantly,  if  fever  develops  in  the  course  of  a 
chronic  otitis,  it  means  either  meningitis  or  thrombosis 
of  the  lateral  sinus.  In  the  former  case  the  fever  is  more 
continuous,  and  chills  are  not  common,  while  sinus  dis- 
ease is  characterized  by  sharp  thermometric  fluctuations, 
often  with  chills.  Yet  this  rule  is  not  absolute.  Ab- 
scess, either  subdural  or  intracranial,  has  but  little,  if 
any,  fever.  When  distinctly  cerebral  symptoms  occur, — 
viz.,  mental  alterations,  coma,  delirium,  pareses  (more 
than  merely  facial), — intracerebral  disease  is  evident,  but 
even  then  a  differential  diagnosis  may  be  difficult.  In- 
flammation of  the  optic  nerve  (optic  neuritis  or  choked 
disc)  is  rather  exceptional  in  all  these  affections,  but  when 
present,  is  very  significant.  All  cerebral  complications 
are  apt  to  produce  the  systemic  disturbance  common  to 
pyogenic  infection — viz.,  derangement  of  the  appetite 
and  digestion,  furred  tongue,  constipation,  and  lack  of 
vigor. 

An  important  diagnostic  method  in  obscure  cases  is 
lumbar  puncture — the  tapping  of  the  spinal  canal  below 
the  spinal  cord.  As  the  question  has  lately  been  raised 
regarding  the  absolute  safety  of  this  procedure,  it  is  best 


5l6  PYOGENIC    EXTENSION    OF    OTITIS. 

to  limit  its  use  to  those  instances  in  which  no  diagnosis 
can  be  made  without  it.  The  technical  details  of  this 
operation  do  not  require  discussion  in  this  place.  The 
information  gained  by  lumbar  puncture  is  positive  as 
to  the  existence  of  meningitis,  negative  regarding  the 
other  complications.  When  the  cerebrospinal  fluid 
escapes  under  abnormal  high  pressure,  but  is  either 
perfectly  clear  or  contains  only  microscopically  leuko- 
cytes, a  serous  meningitis  is  proved.  When  the  fluid, 
however,  is  turbid  and  the  microscope  reveals  the  pres- 
ence of  pus-cells  as  well  as  bacteria,  especially  strepto- 
cocci, it  is  proof  positive  of  a  purulent  meningitis.  In 
abscesses  within  the  skull  and  in  sinus  phlebitis  the  evi- 
dence by  lumbar  puncture  is  negative. 

The  otitic  intracranial  complications  are  most  common 
in  late  childhood  and  early  middle  life,  are  decidedly 
more  frequent  in  the  male  than  in  the  female,  and  occur 
oftener  on  the  right  than  on  the  left  side.  Of  all  the 
lesions,  the  extradural  abscess  is  the  most  frequent  and 
often  the  intermediate  step  between  ear  disease  and  the 
other  complications.  In  the  case  of  acute  otitis  the 
cerebral  sequels  may  not  become  manifest  until  quite  a 
time — even  weeks — has  elapsed  after  the  apparent  cure 
of  the  ear  disease.  The  liability  to  cerebral  complica- 
tions is  very  small  in  those  cases  of  chronic  purulent 
otitis  in  which  free  drainage  is  indicated  by  an  absence 
of  fetor.  The  greatest  danger  is  in  the  cases  with  stag- 
nation of  fetid  pus,  especially  in  the  course  of  subacute 
exacerbations,  particularly  when  caries  or  cholesteatoma 
exist. 

It  is  sometimes  not  possible  to  recognize  with  certainty 
the  existence  of  an  intracerebral  complication  or  to  diag- 
nose the  exact  lesion  prior  to  the  operative  dissection. 
If  in  the  course  of  an  operation  carious  fistulae  or  paths 
of  granulations  are  found,  they  are  to  be  followed  up  to 
wherever  they  lead.  As  with  rare  exceptions  these 
patients  are  sure  to  die  if  not  treated  surgically,  the 
operation  must  not  stop  short  of  the  utmost  obtainable 


EXTRADURAL   OR    SUBDURAL   ABSCESS.  517 

limit.  To  refuse  an  operation  means  sure  death.  In 
every  case  the  suppurative  focus  in  the  temporal  bone 
should  be  completely  eliminated.  This,  indeed,  may  be 
sufficient  for  recovery  from  beginning  sinus  thrombosis, 
serous  meningitis,  possibly  even  circumscribed  purulent 
meningitis.  It  is  prudent  for  the  aurist  of  limited  ex- 
perience to  employ  trained  surgical  assistance. 

The  importance  of  the  subject  demands  a  detailed  dis- 
cussion of  each  lesion,  while  on  account  of  the  rarity  of 
these  complications  this  will  be  made  very  brief 

391.  Extradural  or  subdural  abscess  occurs  between 
the  bone  and  the  external  layer  of  dura  mater,  which 
serves  as  periosteum.  It  begins  always  on  the  temporal 
bone,  rather  oftener  in  the  posterior  than  in  the  middle 
cerebral  fossa.  Exceptionally  it  may  be  situated  deeply 
near  the  apex  of  the  petrous  pyramid.  Its  size  varies 
from  that  of  a  small  to  a  large  nut.  In  the  cases  due  to 
acute  otitis  the  dura  is  usually  covered  with  granulations, 
and  the  pus  is  odorless,  containing  the  pneumococcus 
perhaps  oftener  than  any  other  microbe.  In  chronic 
cases  there  is  apt  to  be  sloughing  of  the  membranes,  and 
the  pus  is  often  fetid.  If  let  alone,  the  abscess  will  in 
rare  instances  break  through  the  tympanic  roof,  or  even 
through  the  squamous  plate  of  the  temporal  bone.  As  a 
rule,  however,  it  proves  fatal  by  leading  to  meningitis  or 
to  sinus  thrombosis  with  pyemia  after  the  lapse  of  weeks 
or  months. 

The  diagnosis  of  extradural  abscess  is  very  obscure. 
There  may  be  scarcely  any  distinctive  symptoms.  Head- 
ache, especially  when  localized,  tenderness,  sometimes 
indicated  by  rigidity  of  the  neck,  are  its  most  frequent 
manifestations.  As  a  rule,  there  is  no  fever  at  all ;  some- 
times a  slightly  abnormal  evening  temperature.  But 
slight  systemic  and  stomach  disturbance,  and  especially 
constipation,  is  often  noted.  Vertigo,  nystagmus,  nau- 
sea, and  vomiting  may  be  present,  but  are  perhaps  of 
otitic  origin.  Distinctive  cerebral  symptoms  are  excep- 
tional and  rather  suggestive  of  other  complications.    The 


5l8  PYOGENIC    EXTENSION    OF    OTITIS. 

most  positive  but  infrequent  evidence  is  circumscribed 
tenderness  with  edema  or  even  a  subperiosteal  abscess 
behind  and  above  the  ear,  due  to  pyogenic  penetration 
along  a  venous  channel  in  the  skull.  In  many  instances 
the  diagnosis  can  be  made  only  by  finding  and  following 
carious  tracks  or  cellular  paths  filled  with  granulations 
during  a  mastoid  operation  demanded  by  the  aural  con- 
dition. 

If  such  carious  or  granulation  paths  are  seen,  they  will 
be  found  to  lead  to  the  abscess  on  persisting  in  the 
judicious  use  of  chisel  and  rongeur  forceps  until  the 
dura  is  exposed  over  a  sufficiently  large  area.  The  dura 
should  not  be  opened  or  curetted  even  if  covered  with 
granulations,  in  order  not  to  excite  a  meningitis.  If 
symptoms  suggesting  a  subdural  abscess  persist  after  a 
properly  performed  mastoid  or  radical  operation  in  which 
the  cranial  cavity  was  not  opened,  a  secondary  operation 
should  be  made.  If  no  local  indications  are  found  along 
which  the  opening  should  be  extended,  the  skull  may 
be  trephined  through  the  squamous  portion.  The  extra- 
dural exploration  should  be  followed  up,  if  necessary,  to 
the  apex  of  the  petrous  pyramid.  A  simple  after-treat- 
ment is  carried  out  along  the  usual  lines  of  modern 
surgery  with  an  iodoform  gauze  drain.  The  mortality  in 
early  operations  of  uncomplicated  subdural  abscess  is 
very  small,  but  increases  materially  when  other  compli- 
cations have  occurred. 

393.  The  intracerebral  abscess,  more  common  in 
chronic  than  in  acute  cases,  is  sometimes,  but  not  as  a 
rule,  secondary  to  a  subdural  abscess.  The  exciting 
microbes  may  spread  along  the  course  of  small  arteries, 
veins,  cerebral  nerves,  or  strands  of  connective  tissue. 
It  is  always  on  the  same  side  of  the  ear,  more  often  in 
the  temporal  lobe  of  the  cerebrum  than  in  the  cerebellum, 
rare  in  the  basal  parts  or  in  the  occipital  lobe.  The  otitic 
abscess  is  single.  If  multiple,  it  may  be  of  pyemic 
origin. 

R.  Miiller  has  lately  tried  to  distinguish  between  inter- 


INTRACEREBRAL   ABSCESS.  5  I9 

stitial  and  parenchymatous  brain  abscess.  In  the  former 
case  the  pyogenic  microbes,  usually  streptococci,  travel 
along  a  connective- tissue  septum  and  produce  a  true 
abscess  with  an  abscess  wall.  These  pus  accumulations 
are  likely  to  cause  pressure  symptoms.  The  parenchy- 
matous abscess,  on  the  other  hand,  is  due  to  the  invasion 
of  the  brain  substance  by  destructive  bacteria.  It  is  often 
due  to  a  mixed  infection  and  contains  fetid  pus,  with 
sloughing  of  the  brain  substance,  but  with  little  inflam- 
mation. It  is  more  apt  to  cause  symptoms  resulting 
from  destruction  than  those  due  to  pressure.  Miiller 
admits,  however,  that  the  majority  of  abscesses  are  of  a 
mixed  type. 

The  beginning  of  brain  abscess  may  or  may  not  be 
indicated  by  vague  symptoms,  general  disturbance,  head- 
ache, nausea,  vomiting,  and  perhaps  slight  fever.  As  a 
rule,  the  abscess  then  follows  a  latent  course  for  weeks  or 
months.  When  its  presence  finally  becomes  manifest, 
we  can  distinguish  between  diffuse  and  focal  symptoms. 
The  former  are  general  malaise,  sometimes  constipation, 
headache,  more  or  less  severe  and  not  necessarily  localized, 
tenderness  of  the  scalp,  slowness  of  the  pulse,  dizziness, 
mental  alterations,  insomnia,  delirium,  and  coma.  These 
symptoms  are  present  to  a  very  variable  extent.  Optic 
neuritis  is  not  common,  but  if  present  is  significant.  The 
focal  symptoms  are  of  greater  importance  for  diagnosis, 
but  may  be  late  or  even  absent.  Abscess  of  the  tem- 
poral lobe  may  cause  deafness  of  the  other  ear,  word- 
deafness,  disturbance  of  speech  and  some  form  of  aphasia, 
especially  if  left-sided  in  a  right-handed  subject,  or  vice 
versd.  If  it  extends  toward  the  internal  capsule,  it  may 
cause  hemi-anesthesia  or  hemianopsia  and  crossed  paraly- 
sis of  the  facial  nerve  and  arm  or  leg  ;  rarely,  spasms.  In 
the  cerebellum  the  abscess  is  likely  to  reveal  itself  by 
localized  occipital  headache,  rigidity  of  the  neck,  ataxia, 
staggering,  vertigo,  and  vomiting.  An  abscess  in  any 
locality  may  raise  the  intracranial  tension  sufficiently  to 
cause  palsy  of  the  various  ocular  muscles. 


520  PYOGENIC    EXTENSION    OF    OTITIS. 

In  the  diagnosis  of  brain  abscess  special  care  must  be 
taken  to  distinguish  it  from  brain  tumor  and  tubercular 
meningitis. 

Without  treatment  abscess  of  the  brain  is  invariably 
fatal,  mostly  by  breaking  into  the  ventricle  and  causing 
meningitis.  By  operation,  however,  over  50  per  cent, 
of  cases  are  permanently  cured.  The  abscess  may  be 
searched  for  from  the  extension  of  the  wound  made  in  a 
mastoid  or  radical  operation,  if  the  latter  is  indicated. 
Otherwise  it  is  preferable  to  open  the  skull  with  a  tre- 
phine or  by  means  of  an  osteoplastic  resection  above  the 
auricle. 

A  crucial  incision  is  made  into  the  dura.  Sometimes 
the  brain  substance  will  protrude  if  the  abscess  is  in  the 
proximity.  No  definite  conclusion  can  be  drawn  from 
the  presence  or  absence  of  brain  pulsation.  It  is  more 
certain,  and  not  any  more  dangerous,  to  explore  the  brain 
with  a  knife  thrust  in  the  suspected  direction  than  with  a 
needle.  Four  centimeters  is  the  limit  of  safety,  for  be- 
yond this  distance  the  ventricle  might  be  tapped.  When 
the  pus  is  found,  the  intracerebral  incision  is  dilated  by 
means  of  forceps  and  a  large  gauze  drain  is" put  in.  The 
after-treatment  is  according  to  ordinary  surgical  princi- 
ples. 

393.  Meningitis  is,  of  all  complications,  the  one  most 
feared.  Purulent  meningitis  was  until  lately  considered 
fatal  and  a  positive  contraindication  to  operations  on  the 
skull.  Yet  a  few  recoveries  have  lately  been  recorded 
after  radical  operations.  The  gloomy  prognosis  when 
the  diagnosis  meningitis  is  first  made  is,  moreover,  some- 
what relieved  by  the  possibility  that  instead  of  a  purulent 
process  it  may  be  the  so-called  serous  meningitis,  which 
ends  in  the  recovery  after  elimination  of  the  suppurating 
focus.  A  serous  meningitis  cannot  be  distinguished  at 
first  from  the  purulent  inflammation  of  the  membranes, 
but,  unlike  the  latter,  it  tends  to  recover}^  after  a  radical 
operation.  In  serous  meningitis  the  brain  membranes  as 
well  as  the  brain  substance  appear  edematous  when  ex- 


MENINGITIS.  521 

posed,  and  upon  incision  a  copious  flow  of  clear  fluid 
ensues.  This  discharge  may  last  several  days.  In  puru- 
lent meningitis  the  purulent  inflammation  of  the  arach- 
noid space  is  at  first  limited  to  the  region  of  the  disease 
in  the  temporal  bone.  It  may  remain  thus  localized  by 
reason  of  adhesions,  and  perhaps  occasionally  heal.  But 
usually  it  spreads  and  reaches  other  distant  areas  of  the 
cerebral  surface.  Sometimes  a  meningitis  of  a  very  acute 
character  is  due  to  the  perforation  of  an  abscess  into  the 
ventricle. 

As  a  rule,  meningitis  begins  with  fever,  which  is  apt 
to  be  continuous  and  high.  Rarely  is  fever  absent — most 
likely  perhaps  in  localized  meningitis  or  in  the  serous 
variety.  Diffuse  severe  headache  is  a  prominent  symp- 
tom, with  rigidity  and  often  forcible  backward  retraction 
of  the  neck.  The  head  is  very  tender  on  motion.  Dizzi- 
ness and  vomiting  are  common.  Soon  other  cerebral 
symptoms  follow,  such  as  various  pareses  of  eye  muscles, 
eyelids,  or  muscles  of  the  extremities.  None  of  the  eye 
symptoms  are  absolutely  diagnostic  either  way.  The  often 
mentioned  boat-shaped  retraction  of  the  abdominal  mus- 
cles is  also  not  constant.  The  mind  may  stay  clear,  but, 
as  a  rule,  becomes  obscured  several  days  before  death. 
Somnolence  or  delirium  may  occur.  When  the  menin- 
gitis extends  down  the  spinal  cord,  the  accompanying 
pain  indicates  this  involvement,  and  corresponding  pareses 
of  the  limbs,  as  well  as  of  the  sphincter  muscles,  may 
ensue. 

A  serous  meningitis  which  simulates  purulent  inflam- 
mation may  disappear  within  a  few  days  or  a  week  after 
thorough  removal  of  all  diseased  bone  and  the  opening  of 
any  abscess.  Purulent  meningitis,,  when  well  pronounced, 
is  probably  always  fatal  within  a  period  of  a  few  days  to 
three  weeks  at  the  latest,  usually  inside  of  the  first  week. 
No  treatment  can  be  advised  directly  against  the  purulent 
form  of  the  disease.  Indeed,  until  recently  most  sur- 
geons abstained  from  any  operation  when  the  diagnosis 
of  purulent  meningitis  was  made. 


522  PYOGENIC    EXTENSION    OF    OTITIS. 

394.  Next  to  extradural  abscess  phlebitis  with  throm- 
bosis of  the  lateral  sinus  is  the  most  frequent  conse- 
quence of  ear  disease,  especially  in  chronic  cases.  It  is 
often,  but  not  always,  the  result  of  an  extradural  abscess 
around  the  sinus — the  so-called  perisinuous  abscess.  In 
other  instances  no  distinct  abscess  is  found  but  merely 
continuity  of  pyogenic  infection  through  the  walls  of  the 
antrum,  as  indicated  by  caries  or  granulation  tissue.  The 
inflammatory  process  may  lead  to  circumscribed  phlebitis 
and  thickening  of  the  sinus  walls,  without  thrombosis. 
On  the  other  hand,  a  thrombosis  may  begin  without 
much  visible  change  in  the  appearance  of  the  venous 
wall.  The  thrombus  is  at  first  small  and  parietal — i.  e.^ 
adherent  to  the  wall,  without  complete  obstruction  of  the 
venous  channel.  It  may  or  may  not  finally  occlude  the 
caliber.  The  thrombus  may  or  may  not  remain  firm  and 
bland,  the  bland  thrombus  being  probably  due  to  the 
action  of  absorbed  toxins,  without  invasion  of  the  clot 
by  living  bacteria.  But  if  not  interfered  with  surgically, 
the  thrombus  is  sure  to  become  septic  at  last.  On  open- 
ing the  sinus  it  will  then  be  found  filled  with  pus  or 
chocolate-colored  decomposed  blood.  Occasionally  the 
wall  remains  apparently  sound,  merely  thickened.  Often, 
however,  in  septic  cases  the  venous  wall  is  discolored 
grayish  or  greenish  and  becomes  perforated  or  even  gan- 
grenous. The  thrombus  may  extend  backward  to  the 
torcular  and  centrally  to  the  jugular  bulb,  or  even  far  into 
the  internal  jugular  vein.  From  the  jugular  bulb  retro- 
grade thrombosis  may  enter  the  petrosal  and  even  the 
cavernous  sinus. 

Systemic  infection  is  sure  to  follow  if  the  changes  in 
the  sinus  are  not  arrested  by  operation  at  an  early  period, 
for  even  in  the  case  of  a  clot  solid  at  both  ends  liquefac- 
tion and  entrance  of  microbes  into  the  circulation  will 
ultimately  take  place.  The  absorption  of  toxins  reveals 
itself  by  fever  and  general  systemic  disturbances,  while 
the  detachment  of  particles  of  the  clot  laden  with  bacteria 


THROMBOSIS    OF   THE    LATERAL   SINUS.  523 

causes  pyemic  metastases,  especially  in  the  joints  and 
lungs  ;  less  often  in  other  viscera. 

395.  At  the  beginning  the  symptoms  of  sinus  throm- 
bosis are  not  very  distinct.  They  are  merely  the  exag- 
geration of  the  disturbances  produced  by  a  severe  mastoid 
process.  Headache  is  rarely  absent,  and  especially  prom- 
inent when  the  thrombosis  is  started  by  a  subdural  ab- 
scess. Malaise  and  gastric  disturbances  may  be  due  to 
the  mastoid  disease  alone.  The  characteristic  symptom, 
however,  is  fever.  Whenever  the  fever  of  an  acute  otitis 
does  not  cease  within  a  few  days,  except  in  children  ; 
whenever  it  increases  suddenly  or  steadily  ;  and  espe- 
cially when  fever  sets  in  in  chronic  afebrile  cases,  sinus 
thrombosis  should  be  at  once  suspected.  Chills  alternat- 
ing with  extensive  fluctuations  in  temperature  establish 
the  diagnosis  ;  yet  there  are  occasionally  rare  exceptions 
to  this  rule.  Tenderness,  edema,  or  inflammatory  swell- 
ing over  the  site  of  the  sinus  are  not  constant,  but  very 
suggestive  symptoms. 

If  the  thrombosis  extends  into  the  jugular  vein,  this  is 
often  indicated  by  perceptible  hardness  and  tenderness 
of  the  vein,  sometimes  with  inflammatory  edema  of 
the  tissues  of  the  neck.  This  condition  must  not  be  con- 
fused with  perforation  of  a  mastoid  abscess  through  the 
internal  surface  of  the  tip. 

The  absorption  of  septic  poisons  is  indicated  only  by 
the  general  systemic  disturbances,  including  enlargement 
of  the  spleen  and  sometimes  jaundice.  Pyemic  metas- 
tases, however,  produce  unmistakable  symptoms.  If 
they  occur  in  the  joints,  the  latter  become  tender  and 
swollen.  In  the  lungs  the  pyemic  emboli  are  revealed 
by  the  occurrence  of  sudden  irritation  and  cough,  and  if 
superficial  enough,  they  can  be  detected  by  dulness  and 
rdles.  The  clinical  picture  may  be  complicated  by  the 
coexistence  of  a  serous  meningitis  with  the  symptoms 
peculiar  to  it. 

With  rare  exceptions  sinus  thrombosis  is  fatal  unless 
treated  surgically.     The  earlier  the  operation,  the  greater 


$24  PYOGENIC    EXTENSION    OF    OTITIS. 

the  chances  of  recovery.  Even  in  unselected  cases  the 
mortality  is  not  over  50  per  cent.,  and  very  much  smaller 
when  all  unnecessary  delay  is  avoided.  If  only  metastases 
into  the  joint  have  occurred,  the  prognosis  is  still  fair  ; 
more  serious,  however,  in  the  case  of  pulmonary  embol- 
ism.    In  any  case  operation  should  be  attempted, 

396.  According  to  the  existing  indications,  the  opera- 
tion should  either  be  the  simple  chiseling  into  the 
mastoid  or  the  radical  clearing  of  mastoid  antrum  and 
tympanic  attic.  The  sinus  is  then  to  be  laid  bare  by 
working  upward  and  backward  from  the  antrum,  using 
small  rongeur  forceps  as  much  as  possible  in  preference  to 
the  chisel.  When  the  indications  are  clear  for  incision 
into  the  sinus,  the  latter  should  be  exposed  to  the  utmost 
extent — 3  to  4  cm.  or  even  a  trifle  more.  Whether  the 
operation  should  include  opening  of  the  sinus  or  not 
must  be  judged  by  the  following  criteria:  If  the  symp- 
toms are  relatively  mild  and  the  sinus  wall  is  not  dis- 
colored, and  the  sinus  is  still  felt  by  the  probe  to  be  a 
channel  containing  fluid  blood,  it  may  be  let  alone  after 
completely  removing  all  diseased  bone  and  exposing  the 
sinus  wall.  The  incision  into  the  sinus  may  not  add  to 
the  danger  of  the  operation,  but,  on  account  of  hemor- 
rhage, it  complicates  the  after-management.  If  the  sep- 
ticemic symptoms  do  not  abate  in  the  course  of  one  to 
two  days,  the  sinus  may  be  opened  at  the  next  dressing 
without  the  necessity  of  narcosis.  But  in  the  case  of 
pronounced  pyemic  symptoms  or  even  in  the  absence  of 
the  latter  when  the  sinus  is  discolored  or  gangrenous  it 
should  be  included  in  the  operation.  Even  when  the 
venous  wall  shows  little  change,  it  may  be  found  that 
the  severe  systemic  symptoms  present  are  due  to  the 
septic  breaking  down  of  the  clot.  The  puncture  of  the 
sinus  by  means  of  a  hollow  needle  is  not  a  reliable  diag- 
nostic method,  as  it  neither  reveals  a  small  parietal  clot 
nor  any  small  accumulation  of  pus  which  it  does  not 
happen  to  strike,  while  it  does  involve  the  danger  of  in- 
fection of  the  dura  if  the  needle  happens  to  perforate  the 


THROMBOSIS    OF    THE    LATERAL   SINUS.  525 

inner  sinus  wall.  The  opening  of  a  sinus  begun  with 
scissors  may  be  finished  with  a  bistoury  on  the  grooved 
director.  The  broken-down  clot  should  be  scooped  out 
until  a  solid  thrombus  is  reached,  and  toward  the  rear 
even  until  the  blood  begins  to  flow.  It  is  best  to  excise 
the  infected  part  of  the  sinus  wall.  Before  the  sinus  is 
opened  the  operation  on  the  bone  or  on  any  existing  sub- 
dural abscess  should  be  completed,  because  hemorrhage 
may  enforce  a  rapid  interruption  of  further  operation. 
It  can,  however,  be  always  checked  by  compression  with 
gauze. 

Opinions  are  divided  as  to  the  advisability  of  ligating 
the  jugular  vein.  Its  exposure  adds  to  the  shock  of  an 
otherwise  necessarily  long  operation  (one  to  two  hours). 
It  is  also  said  that  ligation  of  the  vein  is  neither  an  abso- 
lute preventive  of  pyemia  nor  necessary  in  every  instance 
of  jugular  thrombosis.  Yet  experience  has  shown  that 
the  danger  of  pyemia  is  certainly  diminished  by  elimi- 
nating a  menacing  clot  in  the  jugular  vein.  When 
jugular  phlebitis  can  be  recognized,  it  is  best  to  begin 
the  operation  by  an  extensive  exposure  of  that  vein  in 
the  neck.  It  should  then  be  ligated  below  in  the  appar- 
ently healthy  part,  and  upward  as  close  as  possible  to  the 
jugular  bulb,  and  the  intervening  portion  excised,  with 
ligation  of  the  internal  facial  vein.  If  the  exposure  of 
the  lateral  and  sigmoid  sinus  shows  thrombosis  extend- 
ing to  the  jugular  bulb,  many  good  operators  deem  it 
best  to  ligate  the  jugular  vein  in  the  neck  before  pro- 
ceeding to  clear  out  the  sinus. 


CHAPTER  XLVI. 

DISEASES   OF    THE    INTERNAL    EAR. 

397.  The  labyrinth  is  found  diseased  in  about  5  to  8 
per  cent,  of  ear  patients.  The  differential  diagnosis 
between  lesions  of  the  labyrinth  and  those  of  the  middle 
ear  can  usually  be  made  with  certainty,  but  it  is  often 
impossible  to  distinguish  between  affections  of  the  inter- 
nal ear  and  those  of  the  auditory  nerve,  except  by  the 
history  and  other  concomitant  symptoms.  Since  the 
labyrinth  is  the  organ  of  both  the  sense  of  hearing  and 
of  the  static  sense,  its  disease  may  cause  symptoms 
referable  to  either  or  both.  On  account  of  their  vehe- 
mence the  disturbances  of  the  static  sense  are  apt  to 
predominate  in  the  clinical  scene.  Dizziness  may  vary 
from  a  mere  sense  of  unsteadiness  to  a  feeling  of  passive 
rotation  or  falling.  It  is  relieved  by  rest  in  bed,  but 
may  even  then  be  distressing.  When  severe,  the  diz- 
ziness is  apt  to  lead  to  nausea  and  to  vomiting.  It  may 
also  reveal  itself  by  nystagmus-like  swinging  movements 
of  the  eyes,  generally  of  slow  rhythm.  Vertigo  neces- 
sarily interferes  with  steady  gait.  There  may  be  inco- 
ordination of  movements.  In  pronoimced  instances  the 
sufferer  .steadies  his  walk  by  spreading  the  legs.  The 
dizziness  is  apt  to  last  as  long  as  the  lesion  in  the  semi- 
circular canals  is  of  an  irritative  character.  When  it 
begins  to  decline,  it  is  apt  to  fluctuate  in  severity  with 
periodic  intensification.  In  most  instances  the  dizziness 
ceases  ultimately.  The  patient  learns  to  control  his 
movements  with  the  correlated  aid  of  the  other  senses, 
so  that  finally  he  gets  along  fairly  well  under  ordinary 
circumstances.  But  when  the  eyes  are  closed,  the  un- 
steadiness reappears.  After  extensive  disease  of  the 
semicircular  canals   all   unusual    movements   requiring 

526 


DISEASES    OF   THE    INTERNAL    EAR.  527 

fine  coordination — for  instance,  standing  on  one  leg  or 
balancing — become  difficult  or  impossible. 

398.  The  hearing  may  be  but  moderately  damaged, 
or  it  may  be  entirely  abolished.  Absolute  deafness  is 
a  positive  proof  of  labyrinthine  disease,  except  when 
due  to  destruction  of  the  auditory  nerve.  It  is  charac- 
teristic of  labyrinthine  lesions  that  the  perception  of  high 
tones  is  lost  first.  The  failure  to  hear  the  highest  notes 
of  the  Galton  whistle  proves  disease  of  the  internal  ear. 
If  the  deafness  is  not  absolute,  it  may  be  often  found 
that  there  are  small  "islands"  in  the  auditory  range 
for  which  perception  is  still  retained,  with  a  defect  for  the 
greater  part  of  the  scale.  Tuning-fork  tests  show  that 
bone-conduction  is  reduced  to  the  same  extent  as  air- 
conduction.  The  Rinne  test  is  always  positive,  never 
negative.  The  time  of  perception  of  the  tuning-fork 
placed  on  the  skull  is  reduced  in  proportion  to  the  deaf- 
ness. In  Weber's  test  the  sound  of  the  tuning-fork  is 
referred  to  the  better  ear  if  the  affection  is  not  symmetric. 
When  labyrinthine  disease  is  complicated  by  middle-ear 
lesions,  all  tuning-fork  tests  become  indecisive.  In  such 
cases  dependence  must  be  placed  mainly  on  the  loss  of 
the  high  tones  and  on  the  history. 

Another  symptom  of  cochlear  involvement  is  dipla- 
cusis.  A  musically  trained  ear  hears  certain  or  even 
all  tones  accompanied  by  another  note  one-half  to  one 
tone  higher  or  lower  in  pitch.  As  a  rule,  diplacusis  is 
due  to  hearing  the  "  false  "  note  in  the  affected  ear,  with 
normal  perception  in  the  other,  but  it  may  also  be  due 
to  "double"  hearing  in  the  diseased  ear.  Still  dipla- 
cusis is  very  rare  in  purely  labyrinthine  affections.  This 
symptom,  infrequent  at  best,  is  oftener  met  with  in  slight 
exudative  catarrh  of  the  middle  ear,  denoting,  never- 
theless, a  labyrinthine  complication,  usually  of  a  very 
transient  character.  Tinnitus  is  complained  of  in  all 
affections  of  the  internal  ear,  except  when  the  auditory 
nerve-ends  are  totally  destroyed.  There  is  nothing  about 
the  noises  which  distinguishes  them  from  those  heard  in 


528  DISEASES    OF    THE   INTERNAL    EAR. 

diseases  of  the  middle  ear.     They  are  apt  to  vary  in  in- 
tensity with  the  nervous  condition  of  the  patient. 

Affections  of  the  labyrinth  are  either  complications  in 
the  course  of  middle-ear  disease  or  due  to  descending 
processes  from  the  cranial  cavity,  or,  in  a  minority  of 
cases,  strictly  primary.  Even  of  the  primary  labyrinth- 
ine lesions  many  are  the  result  of  some  previous  systemic 
disease.  As  the  most  striking  type  of  an  affection  of  the 
internal  ear  it  is  best  to  begin  with  the  description  of — 

LABYRINTHINE   APOPLEXY,   OR  MENIERE'S  DISEASE. 

399.  Intralabyrinthine  apoplexy  begins  in  the  form 
of  a  sudden  spell.  The  patient  is  seized  by  intense 
dizziness  and  falls,  usually  remaining  conscious,  but  in 
some  instances  becoming  even  unconscious  for  a  short 
time.  Nausea  and  vomiting  soon  follow.  When  the 
sufferer  regains  his  self-control,  he  notices  intense  noises, 
sometimes  hissing,  sometimes  roaring  or  rumbling  sounds, 
and  discovers  that  he  is  partially  or  totally  deaf,  at  least 
in  one  ear,  sometimes  in  both.  The  spell  usually  begins 
without  warning.  Occasionally  it  is  preceded  by  hours 
of  prodromal  symptoms  of  similar  nature  as  the  spell 
itself,  though  much  less  severe.  At  the  beginning  of 
the  attack  headache  is  sometimes  present.  The  dizziness 
is  apt  to  enforce  rest  in  bed  for  days,  or  even  longer.  The 
attempt  at  walking  results  in  staggering  or  falling.  The 
ataxia  may  betray  itself  even  in  the  handwriting  of  the 
patient.  In  the  course  of  time  he  regains  control  over 
his  movements,  though  his  unsteadiness  is  likely  to  per- 
sist indefinitely,  getting  worse  on  excitement.  The  tin- 
nitus is  often  a  source  of  great  distress.  The  impairment 
of  hearing  is  permanent,  but,  as  a  rule,  stationary  and 
not  progressive.  In  some  instances,  especially  those  of 
a  milder  type,  the  spells  of  labyrinthine  apoplexy  recur 
at  long  intervals.  A  few  times  the  two  ears  have  been 
successively  attacked  in  separate  spells. 

400.  The  well-defined  clinical  picture  sketched  in  the 
preceding  paragraph  constitutes  what  may  with  propriety 


LABYRINTHINE    APOPLEXY,   OR    MENIERE  S    DISEASE.       529 

be  called  Meniere's  disease.  It  is  of  comparatively  rare 
occurrence.  Common  enough,  however,  are  cases  which 
present  more  or  less  of  the  preceding  symptoms,  but 
without  the  clinical  history  and  typical  beginning  char- 
acteristic of  Meniere's  disease.  These  less  well-defined 
forms  of  labyrinthine  disease  may  be  said  to  present 
Meniere's  symptoms.  They  occur  more  or  less  pro- 
nounced in  all  affections  of  the  internal  ear,  no  matter 
what  their  etiology  and  what  their  mode  of  onset.  The 
synonym,  labyrinthine  apoplexy,  is  justified  by  the  result 
of  at  least  one  autopsy  by  Meniere,  in  which  a  bloody 
exudate  was  found  in  the  semicircular  canals.  As  the 
disease  is  by  itself  not  fatal,  there  are  scarcely  any  other 
satisfactory  postmortem  records. 

401.  The  treatment  of  Meniere's  disease  is  very  un- 
satisfactory, lodids  have  been  tried  and  found  useless. 
Pilocarpin  has  received  the  credit  for  an  occasional  mod- 
erate improvement,  but  with  doubtful  propriety.  It  is 
injected  subcutaneously  in  doses  of  6  to  15  milligrams. 
Others  have  injected  it  through  the  Eustachian  catheter. 
It  is  not  at  all  certain  but  what  it  may  be  administered 
just  as  well  by  the  mouth.  Charcot  has  suggested  the 
use  of  quinin  in  single  daily  doses  of  0.5  to  i.  for  some 
six  weeks,  principally  for  the  purpose  of  relieving  the 
distressing  tinnitus  and  dizziness.  He  had  observed  that 
as  the  remnant  of  hearing  disappears  the  noises  cease 
likewise,  and  claimed  that  this  could  be  hastened  by  the 
steady  use  of  quinin.  This  claim  has  been  confirmed 
only  to  a  moderate  extent.  Quinin  should  be  restricted 
to  those  instances  in  which  the  hearing  power  of  the 
affected  ear  has  been  damaged  enough  to  make  it  useless. 

402.  Meniere's  disease  is  in  some  instances  mimicked 
by  spells  due  to  functional  nervous  disease.  Hysteric 
spells,  attacks  of  epileptic  equivalents,  and  even  migrain 
have  been  known  to  cause  vertigo,  nausea  and  vomiting, 
as  well  as  tinnitus,  for  hours.  The  transient  nature  of 
these  symptoms  and  the  absence  of  permanent  impair- 
ment of  hearing  exclude  actual  labyrinthine  disease. 

34 


530  DISEASES    OF   THE    INTERNAL    EAK. 

Meniere's  symptoms  without  the  typical  onset  of  laby- 
rinthine apoplexy  occur  under  a  variety  of  conditions, 
occasionally  as  complications  of  middle-ear  disease.  It 
will  be  most  convenient  to  describe  these  various  aflfec- 
tions  according  to  an  etiologic  classification. 

403.  In  the  course  of  non-suppurative  affections  of 
the  middle  ear  the  labyrinth  is  occasionally,  but  not 
often,  involved.  Whenever  there  occurs  ankylosis  of 
the  stapes  or  ossification  of  the  round  window,  a  gradual 
atrophy  of  Corti's  organ  may  follow,  which  can  be  de- 
tected by  the  loss  of  perception  of  the  highest  notes  of 
the  Galton  whistle  and  the  impairment  of  bone-conduc- 
tion. The  form  of  disease  described  in  Chapter  XXXVIII. 
as  sclerosis  or  rarefaction  of  the  bony  capsule  of  the 
labyrinth  impairs  hearing  at  first  only  by  reason  of  the 
rigidity  of  the  oval  window,  and  is  not,  hence,  primarily 
a  disease  of  the  membranous  labyrinth.  After  years, 
however,  it  is  likely  to  end  in  partial  atrophy  of  the 
nerve  terminations.  A  rare  complication  of  catarrh  of 
the  middle  ear  is  a  partial  and  incomplete  attack  of 
labyrinthine  vertigo — a  rudimentary  form,  so  to  speak, 
of  Meniere's  disease.  Purulent  otitis  complicated  by 
caries  may  invade  the  labyrinth,  especially  in  poorly 
nourished  individuals.  The  most  frequent  lesion  found 
in  radical  operations  is  a  carious  spot  in  the  walls  of  the 
horizontal,  less  often  the  posterior  semicircular  canal  or 
in  the  vestibule.  It  reveals  itself  b\'  incessant  vertigo, 
sometimes  with  vomiting  fits,  and  often  with  nystagmus. 
Jansen,  the  only  one  who  has  published  any  experience, 
does  not  hesitate  to  scoop  out  the  carious  spot  with  very 
small  drills  or  curets,  in  order  to  allow  the  intralabyrin- 
thihe  pus  to  escape.  In  order  to  avoid  the  facial  nerve 
this  operation  must  be  made  either  several  millimeters 
behind  the  Fallopian  canal  or  anterior  to  it  in  the  region 
of  the  promontory.  He  has  obtained  a  satisfactory  per- 
centage of  cures.  The  purulent  otitis  media  of  scarlet 
fever  and  measles  is  sometimes  complicated  by  purulent 
destruction  of  the  entire  labyrinth  with  Meniere's  symp- 


TRAUMATISM.  53 1 

toms  and  total  deafness.  In  some  instances  the  whole 
cochlea  becomes  necrotic  and  may  be  expelled  by  suppura- 
tion. 

404.  Traumatism  by  means  of  sharp  utensils  may 
reach  the  labyrinth  through  the  meatus  and  drumhead 
and  bring  on  the  characteristic  symptoms.  The  internal 
ear  may  also  become  involved  in  fractures  of  the  tem- 
poral bone  at  the  base  of  the  skull.  There  may  thus 
occur  a  traumatic  form  of  typical  labyrinthine  apoplexy. 
Violent  disturbances  of  equilibrium  and  vertigo  have 
occurred  a  number  of  times  in  consequence  of  accidental 
or  intentional  exarticulations  of  the  stapes  in  the 
course  of  operations  upon  the  ossicles.  The  symptoms 
have  sometimes  been  mild  and  transient,  but  have  in 
other  cases  necessitated  rest  in  bed  for  weeks,  and  even 
left  some  permanent  impairment.  Evidences  of  laby- 
rinthine involvement — possibly  slight  hemorrhage — are 
sometimes  observed  after  violent  blows  upon  the  ear, 
occasionally  with  long  persistence  of  symptoms. 

Another  external  influence  which  has  produced  a  num- 
ber of  instances  of  labyrinthine  disease  with  Meniere's 
symptoms  of  variable  severity  is  the  sojourn  in  com- 
pressed-air  caissons  used  in  submarine  work  and 
bridge-building.  The  attack  comes  on  when  the  work- 
man leaves  the  compressed-air  chamber.  It  is  presum- 
ably due  to  the  liberation  of  the  absorbed  gases  in  the 
capillaries  of  the  labyrinth  when  the  external  pressure  is 
removed  too  suddenly.  The  damage  is  usually  of  a 
permanent  character  in  these  cases. 

405.  Unusually  loud  sounds,  especially  explosions, 
are  likewise  an  occasional  cause  of  labyrinthine  symptoms, 
mainly  in  the  form  of  tinnitus  or  partial  loss  of  hearing. 
As  a  rule,  the  damage  .is  transient.  More  permanent  is 
the  influence  of  persistent  din,  to  which  some  trades, 
especially  that  of  boilermakers,  are  subject.  Of  me- 
chanics working  under  such  extremely  noisy  surround- 
ings a  large  proportion  find  the  hearing  gradually  im- 
paired  in   the   course   of   years.      Middle-ear  affections 


532  DISEASES    OF    THE    INTERNAL    EAR. 

seem  to  predispose  to  some  extent  to  this  so-called  boiler- 
makers'  disease  of  the  labyrinth.  But,  on  the  other 
hand,  it  has  been  noticed  that  whenever  more  advanced, 
one-sided  middle-ear  lesions  interfere  with  sound-conduc- 
tion, the  ear  of  that  side  does  not  suffer  so  much  in  the 
end  as  its  mate.  The  labyrinth  is  shown  to  be  the  seat 
of  boilermakers'  deafness  by  the  loss  along  the  upper 
end  of  the  auditory  scale  and  the  impaired  bone-conduc- 
tion. Tinnitus  and  vertigo  are  not  usually  complained 
of.  It  is  not  quite  settled  whether  the  use  of  firm  cotton 
plugs  in  the  ear  affords  protection  against  the  influence 
of  such  loud  dins. 

406.  Drug"  action  has  in  rare  instances  injured  the 
labyrinth.  Large  doses  of  quinin  produce  a  characteristic 
roaring,  which  ordinarily  ceases  within  less  than  twenty- 
four  hours.  There  are  on  record,  however,  a  number  of 
instances  of  more  or  less  complete  permanent  deafness, 
always  bilateral,  traceable  to  excessive  quantities  of 
quinin.  Experiments  on  animals  have  shown  that  poi- 
sonous doses  may  cause  effusion  of  blood  into  the  laby- 
rinth. The  same  has  been  found  true  of  salicylate  of 
sodium.  Clinically,  however,  the  latter  has  very  rarely 
done  any  permanent  damage  to  the  hearing.  Yet  in 
rare  instances  patients  claim  that  a  moderate  tinnitus, 
due  to  middle-ear  disease,  has  been  permanently  intensi- 
fied by  large  doses  of  salicylate  of  sodium. 

407.  Labyrinthine  involvement,  mainly  confined  to 
the  auditory  nerve-ends  (partial  deafness  and  tinnitus),  is 
observed  in  rare  instances  in  the  course  of  various  infec- 
tious diseases,  such  as  typhoid,  typhus,  pernicious  ane- 
mia, etc.  There  are,  however,  some  forms  of  systemic 
disease  in  which  the  labyrinth  suffers  with  greater  fre- 
quency. In  leukocythemia  complete  or  incomplete 
attacks  of  Meniere's  disease  have  been  observed  re- 
peatedly. Mumps  is  known  to  localize  itself  at  times 
in  the  internal  ear,  resulting  in  complete  deafness,  from 
which  very  few  recoveries  have  been  recorded.  This 
metastasis,  one-sided  oftener  than  bilateral,  occurs  rarely 


SYPHILIS. 


533 


at  the  beginning,  oftener  during  the  course  or  after  the 
termination  of  mumps.  There  may  be  with  it  some 
pain  and  considerable  tinnitus. 

408.  Syphilis  is  accused  often  as  a  cause  of  labyrinth- 
ine disease,  but  according  to  personal  experience,  as  well 
as  published  reports  in  literature,  the  localization  in  the 
labyrinth  is  really  very  rare  in  the  acquired  form  of  the 
disease.  It  is  apparently  more  frequent  in  congenital 
syphilis,  occurring  in  females  more  than  in  males,  and 
usually  between  the  ages  of  eight  to  twenty  years.  Con- 
genital syphilis  localizing  itself  in  the  labyrinth  coin- 
cides often  with  or  follows  syphilitic  keratitis,  and  the 
subjects  generally  show  the  malformation  of  the  upper 
incisor  teeth  known  as  Hutchinson's  teeth.  In  the  ac- 
quired form  a  few  casual  observations  have  shown  the 
labyrinth  filled  with  an  inflammatory  non-purulent  exu- 
date, presumably  preceded  by  syphilitic  disease  of  the 
blood-vessels.  Autopsies  at  a  later  stage  have  shown 
osseous  transformation  of  the  labyrinth  with  disappear- 
ance of  the  nerve-fibers.  The  labyrinthine  affection  in 
both  the  acquired  and  the  congenital  forms  may  assume 
the  apoplectic  type,  or  may  in  an  acute  manner  destroy 
rapidly  the  hearing  without  vertigo.  In  other  instances 
the  affection  has  been  of  a  slower  character  and  some- 
times did  not  proceed  to  complete  deafness.  As  a  rule, 
it  is  double-sided.  Specific  treatment  has  had  no  posi- 
tive effect  in  most  instances.  In  the  slower  forms  it  is 
not  even  possible  to  arrest  the  disease  with  certainty. 
Sometimes,  however,  moderate  recovery  has  been  ob- 
served, which  by  some  surgeons  has  been  attributed  to 
the  use  of  pilocarpin  in  addition  to  specific  treatment. 

409.  A  typical  labyrinthine  affection  is  a  frequent  un- 
fortunate outcome  of  cerebrospinal  meningitis.  Its 
percentage  varies  somewhat  with  the  type  of  the  disease. 
After  severe  epidemics  of  cerebrospinal  meningitis  its 
victims  constitute  a  large  part  of  the  deaf-mutes  of  the 
locality.  The  disease,  as  well  as  its  labyrinthine  com- 
plication, occurs  principally  in  children.     Its  beginning 


534  DISEASES    OF   THE    INTERNAL    EAR. 

is  usually  overlooked  on  account  of  the  severity  of  the 
primary  disease  and  the  somnolence  or  coma  so  fre- 
quently present.  As  the  patient  recovers,  he  finds 
himself  completely  deaf  and  generally  distressingly 
dizzy.  The  vertigo  improves,  the  staggering  gait  be- 
comes steadier,  after  a  while  incoordination  occurs  only 
under  trjdng  circumstances,  but  the  deafness  remains. 
Postmortems  have  shown  the  lesion  to  be  a  suppurative 
inflammation  extending  along  the  auditory  nerve  into 
the  labyrinth  and  destroying  both  the  trunk  of  the 
nerve  and  its  ends. 

A  prifnajy  inflatnmation  of  the  labyrinth  with  fever, 
headache,  dizziness,  and  deafness  has  been  described  by 
Voltolini  in  children.  This  affection,  however,  is  now 
generally  believed  to  be  an  abortive  form  of  cerebro- 
spinal meningitis. 


CHAPTER   XLVII. 

DISEASES   OF   THE   AUDITORY    NERVE.— DEAF- 
MUTISM. 

410.  Anatomy  of  the  Auditory  Nerve. — The  eighth 
cranial  nerve  pursues  a  short  course  from  its  emergence 
at  the  side  of  the  medulla  oblongata  underneath  the  pons 
to  the  internal  meatus  in  the  middle  of  the  posterior  sur- 
face of  the  petrous  pyramid.  It  is  joined  by  the  seventh 
or  facial  nerve  in  its  course,  which  leaves  it  in  the  depth 
of  the  internal  meatus  to  pass  over  the  vestibule  into  the 
Fallopian  canal.  The  auditory  nerve  consists  of  two 
branches  really  representing  separate  nerves,  the  cochlear 
branch  or  posterior  lateral  root,  and  the  vestibular  nerve, 
or  anterior  median  root.  The  independence  of  these  two 
branches  is  shown  both  by  their  separate  peripheral  dis- 
tribution and  their  separate  central  course.  Besides,  the 
vestibular  nerve  receives  its  medullary  investment  earlier 
during  embryonic  life  than  the  cochlear  nerve.  The 
cochlear  nerve-fibers  pass  through  the  spiral  ganglion  in 
the  interior  of  the  modiolus.  The  first  neuron  of  this 
nerve  consists  of  the  fibers  in  the  lamina  spiralis,  periph- 
eral to  the  spiral  ganglion.  The  second  neuron  begins 
in  the  latter  and  terminates  in  the  anterior  or  ventral 
and  posterior  or  dorsal  auditory  nuclei  in  the  medulla. 
Thence  the  further  path  is  by  means  of  fibers  in  the 
trapezoid  body  and  striae  acusticse,  which,  decussating, 
pass  forward  in  the  lateral  inferior  fillet  (lemniscus)  to 
the  posterior  corpora  qiiadrigemina.  Through  the  sub- 
thalamic region  and  posterior  part  of  the  internal  cap- 
sule they  finally  reach  the  cortex  of  the  temporal  lobe, 
in  which  they  terminate.  The  vestibular  nerve  is  inter- 
rupted by  a  ganglion  in  the  internal  meatus,  whence  its 
fibers  enter  the  vestibule  and  ampullae.     The  nerve  ends 

535 


536    DISEASES    OF   THE   AUDITORY    NERVE. — DEAF-MUTISM. 

in  a  dorsal  nucleus  in  the  floor  of  the  fourth  ventricle. 
Its  subsequent  connections  have  been  traced  into  the  cere- 
bellum, but  are  not  yet  completely  known. 

411.  Affections  of  the  auditory  nerve  central  to  the 
labyrinth  are  quite  rare  and  are  oftener  seen  by  neurolo- 
gists than  by  otologists.  As  in  labyrinthine  disease,  the 
deafness  is  characterized  by  impairment  of  bone-conduc- 
tion as  well  as  air-conduction,  but,  unlike  the  latter,  it 
is  stated  that  the  perception  of  the  highest  notes  does 
not  suffer  first.  Tinnitus  is,  as  a  rule,  not  so  pronounced 
as  in  labyrinthine  disease  or  is  even  absent.  The  deaf- 
ness, too,  is  not  necessarily — indeed,  rarely — associated 
with  vertigo.  The  diagnosis,  however,  must  be  based 
largely  on  other  concomitant  nervous  symptoms. 

The  auditory  nerve  trunk  suffers  from  degeneration  in 
a  small  proportion  of  patients  with  tabes.  The  atrophy 
is  of  the  same  character  as  the  lesion  of  the  optic  nerve, 
which  latter,  however,  is  much  more  common.  It  is  not 
certain  whether  there  ever  occurs  a  true  neuritis  of  the 
auditory  nerve,  except  as  a  complication  of  adjoining 
inflammatory  processes.  Deafness,  sometimes  one-sided, 
does  occur  when  basilar  disease,  localized  meningitis,  or 
especially  syphilitic  disease  involves  the  auditory  nerve, 
but  all  this  is  very  rare.  The  intracerebral  nerve  path  may 
suffer  from  hemorrhagic  effusions,  tumors,  and  abscesses. 
On  the  basis  of  the  involvement  of  the  auditory  nerve,  a 
localizing  diagnosis  cannot  be  made,  since  its  symptoms 
have  been  observed  in  consequence  of  disease  of  the 
cerebellum,  as  well  as  of  the  corpora  quadrigemina,.  sub- 
thalamic region,  internal  capsule,  and  temporal  lobe. 
When  the  process  is  distinctly  one-sided,  it  is  the  oppo- 
site ear  which  becomes  deaf.  This  has  a  special  bearing 
in  the  case  of  ab.scesses  of  otitic  origin  situated  in  the 
temporal  lobe. 

Besides  actual  deafness  disease  of  the  temporal  lobe 
may  result  in  what  has  been  termed  word-deafness,  or 
amnesic  aphasia.  The  patient  hears,  but  does  not  under- 
stand the  significance  of  the  words.     He  can  repeat  the 


DEAF-MUTISM.  537 

words  mentioned,  but  he  cannot  recall  the  words  for  inde- 
pendent speech.  This  mental  deafness  is  observed  only 
when  the  left  temporal  lobe  is  diseased  in  right-handed 
subjects,  or  vice  versa. 

412.  Purely  functional  deafness  occurs  at  times  in 
hysteria.  Neurologists  often  find  that  in  hysteric  sub- 
jects unilateral  anesthesia  extends  into  the  meatus  up  to 
the  drumhead  and  is  accompanied  by  a  one-sided  reduc- 
tion of  hearing,  of  which  the  patient  is  not  conscious. 
The  hearing  can  be  restored  by  suggestive  influences, 
such  as  electricity  or  metallotherapy.  More  striking, 
however,  is  the  occasional  occurrence  of  sudden  absolute 
bilateral  deafness  in  hysteric  subjects,  usually  due  to  emo- 
tions or  viciously  concentrated  attention  and  sometimes 
accompanied  by  speechlessness.  The  absence  of  vertigo, 
of  nausea,  and  of  subjective  noises  distinguishes  the  hys- 
teric deafness  from  Meniere's  disease.  Under  suggestive 
influences  hysteric  deafness  may  disappear  as  suddenly 
as  it  occurred,  while  otherwise  it  may  last  indefinitely. 

DEAF-MUTISM. 

413.  Since  speech  is  normally  dependent  upon  the  re- 
tention and  repetitions  of  auditory  impressions,  a  child 
born  deaf  cannot  learn  to  speak  in  the  normal  way. 
Even  after  speech  has  been  learned  it  is  again  forgotten 
if  deafness  supervenes  before  a  certain  age.  This  age- 
limit  is  about  the  seventh  year,  being  somewhat  variable 
with  the  intelligence  of  the  child.  It  is  only  after  the 
auditory  centers  have  become  fully  developed  that  the 
impressions  once  stored  up  in  them  remain  permanent 
without  fresh  additions. 

Deaf-mutes  are  either  born  deaf  or  have  become  so  dur- 
ing early  childhood.  Both  classes  are  about  equal  in 
number.  The  proportion  of  deaf-mutes  to  the  total  popu- 
lation is  66  in  100,000  in  this  country,  and  varies  in 
Europe  from  43  in  Holland  to  245  in  100,000  in  Switzer- 
land. Males  predominate  slightly  over  females.  Among 
the  determining  conditions  heredity  is  to  be  mentioned 


53^  DEAF-MUTISM. 

in  the  first  place.  Among  the  descendants  of  deaf-mutes 
the  defect  occurs  in  every  eleventh  instance  according  to 
statistics,  while  parents  with  normal  hearing  have  but  one 
deaf  child  in  every  10,000.  Statistics  further  show  that 
the  hereditary  influence  is  not  merely  a  matter  of  direct 
transmission,  but  that  the  chances  of  deaf  progeny  are 
very  much  increased  by  the  occurrence  of  the  same 
anomaly  among  the  brothers  and  sisters  of  the  parents, 
even  if  the  latter  be  normal.  The  family  influence  is  often 
revealed  by  the  multiple  occurrence  of  deaf-mutism 
among  many  or  all  the  children  of  one  family.  It  has 
also  been  shown  that  the  first  child  runs  greater  chances 
of  deafness  than  the  subsequent  offspring.  Consanguinity 
of  the  parents  seems  a  predisposing  factor ;  more  so,  how- 
ever, by  the  cumulative  effect  of  unfavorable  family 
influences  than  merely  by  inbreeding.  Other  instances 
of  degeneration,  idiocy,  epilepsy,  and  retinitis  pigmen- 
tosa appear  often  in  the  family  history. 

The  direct  cause  of  congenital  deafness  is  mainly  an 
inflammatory  affection  of  the  labyrinth,  sometimes  local- 
ized more  in  the  semicircular  canals,  sometimes  more  in 
the  cochlea.  The  inflammatory  lesions  are  seen  only  in 
early  autopsies.  In  later  examinations  the  labyrinth  is 
found  ossified  and  sometimes  apparently  absent.  Mal- 
formations of  the  petrous  bone,  suggested  by  narrowness 
or  even  obliteration  of  the  internal  meatus  and  a  rudi- 
mentary condition  of  the  tympanic  cavity,  are  not  often 
observed  and  may  be  secondary  to  a  fetal  labyrinthine 
inflammation.  In  some  instances  the  third  frontal  con- 
volution of  the  left  side  of  the  cerebrum  and  the  adjoin- 
ing part  of  the  island  of  Reil  have  been  found  atrophied, 
evidently  because  the  speech  center  has  never  become 
developed. 

Acquired  deaf-mutism  is  the  result  of  the  various  laby- 
rinthine affections  described  in  the  previous  chapter.  In 
most  statistics  cerebrospinal  meningitis  occupies  the  first 
place  in  etiology.  Next  to  it  come  scarlet  fever,  diph- 
theria, measles,  and  syphilis.     The  other  infectious  dis- 


DEAF-MUTISM.  539 

eases  and  brain  diseases  like  internal  hydrocephalus  are 
less  frequent  causes. 

414.  In  acquired  deaf-mutism  the  hearing  is  almost 
always  totally  destroyed.  In  the  congenital  form,  how- 
ever, it  is  not  uncommon  to  find  remnants  of  auditory 
perception  comprising  a  small  range  of  tones  in  different 
parts  of  the  scale.  In  the  acquired  form  dizziness  may 
persist  to  a  variable  extent  for  many  months  after  the 
beginning,  but  it  always  ceases  in  the  end.  Most  deaf- 
mutes,  however,  do  not  possess  perfect  coordination,  at 
least  in  difficult  movements.  Feats  of  balancing,  for 
instance,  are  learned  only  with  difficulty  and  depend 
mainly  on  the  control  by  sight.  On  the  other  hand,  the 
majority  of  deaf-mutes  are  not  made  dizzy  by  whirling 
on  account  of  the  destruction  of  the  semicircular  canals. 
The  intelligence  of  deaf-mutes  is  usually  not  impaired; 
they  are  often  very  bright  and  observant.  It  is  notice- 
able, however,  that  they  are  apt  to  be  emotional  and  lack 
self-control,  which  may  be  partly  the  result  of  insufficient 
training,  partly  the  expression  of  a  degenerative  ten- 
dency. A  striking  fact  is  the  frequent  occurrence  of  an 
enlarged  pharyngeal  tonsil  at  least  in  one-third,  and 
according  to  some  authors  in  two-thirds  of  all  deaf- 
mutes.  However  important  the  removal  of  this  anomaly 
may  be,  it  must  not  be  expected  to  benefit  the  hearing. 

Unless  specially  trained,  deaf-mutes  utter  no  sounds 
except  a  few  inarticulate  tones  of  emotional  origin. 
Their  natural  mode  of  communication  is  by  gestures. 
As  a  rule,  they  learn  reading  and  writing  very  easily 
under  competent  teachers.  Formerly  the  letters  were 
taught  them  by  sign  language  or  by  movements  of  the 
fingers  and  hands.  Their  sphere  of  utility  is,  however, 
much  enlarged  by  learning  to  speak  and  to  read  language 
by  watching  the  lips.  The  younger  the  training  is  begun 
the  easier  it  is  for  a  child  to  acquire  this  skill,  and  the 
more  nearly  perfect  will  be  his  enunciation.  The  speech 
of  a  deaf-mute  will  always  betray  him  to  an  experienced 
observer,  but  in  many  instances  he  can  get   along  ex- 


540  DEAF-MUTISM. 

cellently  for  an  active  business  career.  Good  teachers 
prefer  to  begin  instruction  before  the  fourth  year  of  life. 
When  there  is  any  remnant  of  hearing  left,  its  methodic 
exercise  enlarges  the  mental  horizon  and  improves  the 
enunciation.  The  exercise  is  carried  on  by  speaking  into 
an  ear  trumpet. 

415.  Deaf-mutism  is  in  rare  instances  simulated  by  a 
peculiar  form  of  mental  disturbance  in  children.  This 
was  first  described  by  Wilde,  but  has  received  very  little 
attention  in  otologic  literature.  Recently  some  cases 
were  reported  by  Moyer,  and  the  writer  has  personally 
seen  3  instances.  These  children  do  not  acquire  speech 
and  apparently  do  not  understand  words  addressed  to 
them.  Some  of  them  are  quite  apathetic  as  regards 
noises  of  any  kind  or  as  regards  speech.  Yet  in  several 
instances  closer  tests  showed  that  words  spoken  in  only 
moderately  loud  tones  were  distinctly  heard  when  the 
child's  attention  was  enforced.  The  words  could  be  cor- 
rectly repeated,  and  when  the  child  was  willing,  it  could 
follow  commands  which  it  evidently  understood.  There 
was  hence  no  complete  deafness,  though  undoubtedly 
some  defect  of  hearing.  Neither  was  there  entire  in- 
activity of  the  sensory  or  motor  parts  of  the  speech 
center.  The  defect  is  evidently  one  of  mental  origin, 
and  can  probably  be  partially  or  wholly  overcome  by 
persistent  patient  training. 


%iLfr.'=?^rf»-;o    ■:,,'«>•- -«^-(t.vl{   i.t^''4».U.    ■■    ■    <^-j-.i--- 


PLATE   II. 

Fig.    I.— Normal  membrana  tympani  (left  ear — adult). 

Fig.   2. — Retracted  drumhead  ;    boy  with  adenoids  and  neglected  Eusta 
chi&n  catarrh   (right  ear). 

Fk;.  3. — Yellowish  exudate  within  the  tympanic  cavity,  seen  through  a 
slightly  cloudy  drumhead  in  a  middle-aged  man  who  had  had  several  previous 
attacks  of  serous  catarrh  (right  ear). 

Fig.  4. — Cloudy  and  slightly  retracted  membrane;  elderly  woman  with 
adhesive  middle  ear  disease  of  long  duration  (right  ear). 

Fig.  5. — Right  drumhead  in  acute  otitis  which  healed  ultimately  without 
perforation  (girl  of  eighteen  years). 

Fig.  6. — An  old  healed  scar  in  the  (left)  membrane  after  purulent  otitis. 
Hearing  slightly  impaired. 

Fig.   7. — Acute  otitis  media  on  the  second  day  (right  ear). 

Fig.  8. — The  drumhead  of  Fig.  7  two  days  later,  after  paracentesis  had 
been  done  and  gauze  drainage  maintained. 

Fig.  9. — Old  case  of  suppuration  of  the  attic  with  perforation  in  Shrap- 
nell's  membrane,  through  which  the  injected  mucous  membrane  is  visible  ;  the 
(right)  drumhead  slightly  cloudy  and  retracted  ;  fair  hearing. 

Fig.  10. — Chronic  purulent  otitis  dating  back  to  scarlet  fever,  with  large 
perforation,  through  which  the  mucous  membrane  of  the  internal  tympanic 
wall  is  seen  swollen  and  granulated  (left  ear). 

Fig.  II. — The  drumhead  of  Fig.  10  three  weeks  later,  after  the  disease 
had  been  healed  by  boric  acid  insufflations  ;  the  tympanic  lining  is  now  pale 
and  smooth  ;  the  handle  of  the  hammer  is  adherent  to  the  inner  tympanic  wall 
(young  girl). 

Fig.  12. — Defect  caused  by  former  caries  in  the  bony  margin  around 
Shrapnell's  membrane;  a  cholesteatomatous  collection  in  the  attic  protrudes 
through  the  gap  ;  no  discharge  at  the  time  ;  fair  hearing,  altliough  the  drum- 
head is  thickened. 


Plate  II. 


gn 

^^^^H^H 

B 

INDEX. 


A. 

Abscess  of  brain,  518 

mastoid,  479 

subperiosteal,  478,  481 

of  nasal  septum,  165 

peritonsillar,  234 

retropharyngeal,  236 

subdural  or  extradural,  517 
Accessory  nasal  cavities,  369.     See 

Simis. 
Adenoid  vegetations,  249 

operations  of,  258 
Adenoma  of  nose,  317 
Age,   influence  of,  in  diseases  of 

nose  and  throat,  49 
Air-conduction  of  sounds,  379,  400 
Air-passages,  development  of,  17 

mucous  membrane  of,  29 

syphilis  of,  293 

vascular  supply  of,  32 
Alae  nasi,  collapse  of,  196 
Alcohol,  influence  upon  throat,  49, 

239 
Angina,  226 

Angiomatous  tumors  of  nose,  314 
Annulus  tympanicus,  351 
Antisepsis  of  nasal  wounds,  83 
Antrum   of   Highmore,    120.     See 

Maxillary  sinus. 
Anvil,  360 
Aprosexia,  252 

Aqueducts  of  internal  ear,  373 
Asch  operation,  210 
Asthenopia  of  nasal  origin,  341 
Asthma,  336 
Attic  of  middle  ear,  354,  362 

exposure  by  radical   opera- 
tion, 499 

inflammation  of,  469 


Audiphone,  414 

Auditory  nerve,  anatomy  of,  535 

diseases  of,  536 
Auricle,  diseases  of,  415 
Autumnal  catarrh,  272 

B. 

Bathing,  injuries  to  ear  in,  386 

Baths,  influence  of,  upon  respira- 
tory passages,  44 

Belloc's  sound,  80 

Boiler-maker's  deafness,  531 

Bone-conduction  of  sounds,  380, 
400 

Brain,  abscess  of,  518 

Bulla  ethmoidalis,  113 

Bursa,  pharyngeal,  246 

C. 

Caisson  disease,  531 
Cancer  of  nose,  317 

of  pharynx,  320 
Caries  in  middle-ear  disease,  506 
Catarrh,  autumnal,  272 

chronic    nasal,  classification   of, 
92 

Eustachian,  429 

proliferative,  of  middle  ear,  442 

retronasal,  174 

serous,  of  middle  ear,  433 

syphilitic,  of  middle  ear,  442 
Cauterization  in  the  nose,  74 
Cavernous  tissue  in  nose,  33 

enlargement  of,  168 
Cerebrospinal  meningitis,  533 
Cerumen  glands,  350 

plugs  of,  420 
Cholesteatoma,  508 

541 


542 


INDEX. 


Chondroma  of  nose,  316 
Chorda  tympani  nerve,  354 

division  of,  510 
Chorea,  reflex  nasal,  340 
Chromic   acid,  cauterization   with, 

74 
Cicatrices  in  drumhead,  406 

in  pharynx,  326 
Chmate,  influence  of,  45 
Cocain,  71 
Cochlea,  371 
Cochlear  duct,  374 
Cold  feet,  influence  of,  43 

prevention  of,  42 

taking,  40 
Collapse  of  alae  nasi,  196 
Concretions,  tonsillar,  238 
Coryza,  86 

complications  of,  89 

diagnosis  of,  90 

treatment  of,  90 

vasomotoria,  171 
Cough,  reflex,  336 
Crests  on  septum,  204 

operation  upon,  214 
Cysts  in  maxillary  sinus,  135 

of  nose,  315 

D. 

Deaf-mutism,  537 

of  mental  origin,  540 
Deafness,  boilermaker's,  531 

hysterical,  537 
Development  of  air-passages,  17 

of  ear,  345 
Diabetes,  311 
Diphtheria,  279 

bacillus  of,  283 

influence    of,    upon     ear,    390, 
466 

nasal,  167,  282 
Diplacusis,  396,  527 
Drumhead,   354.     See  Membrana 
tympani. 

artificial,  494 

cicatrices  in,  406 

paracentesis  of,  412 
Duct,  cochlear,  374 


E. 

Ear,  anatomy  of,  347 
development  of.  345 
diseases,  etiology  of,  386 
microbic  parasites  of,  389 
symptoms  of,  394 
foreign  bodies  in,  423 
frost-bites  of,  426 
hemorrhage  from,  427 
inflation  of,  408 
injuries  of,  427 
internal,  370 

syphilis  of,  533 
middle,  353 
syphilis  of,  441 
tuberculosis  of,  510 
physiology  of,  376 
speculum,  403 
trumpets,  413 
tumors  of  425 
Earache,  394.     See  also  Otalgia. 
Eczema  of  auricle  of  ear,  416 

of  nasal  vestibule,  85 
Edema    of    nasal    mucous    mem- 
brane, 185 
of  uvula,  223 
Electrolysis   of   Eustachian    tube, 
450 
of  septum  hypertrophies,  125 
Embryologic    formation    of    nose, 
17,  18 
of  palate,  18 
Empyema,  multiple,  of  sinuses,  152 
of  frontal  sinus,  137 
of  maxillary  sinus,  126 
of  ethmoid  cells,  144 
Epilepsy,  reflex  nasal,  340 
Epistaxis,  220 
Equilibrium,  sense  of,  380 
Ethmoid  bone,  anatomy  of,  109 
cells,  113 

operation  upon,  148,  153 
suppuration  of,  144 
Ethmoiditis,  necrosing,  148 
Ethmoturbinal    lamellae,    19,    in, 

112 
Etiology  of  ear  disease,  386 
of  nasal  and  pharyngeal  diseases, 
40 


INDEX. 


543 


Eustachian  tube,  anatomy  of,  363 

catarrh  of,  429 

catheter,  409 

electrolysis  of,  450 

inflation  of,  408 

patency  of,  407 

stenosis  of,  446 
Exophthalmic  goiter,  reflex  nasal, 
340 

F. 

Facial  paralysis    in   ear    disease, 

510 
Fibroma  of  nose,  3 1 5 

of  pharynx,  318 
Fissures  in  nasal  vestibule,  85 
Foreign  bodies  in  ear,  423 

in  nose,  322 
Fossa,  Rosenmiiller's,  29 
Fractures  at  the  base  of  skull,  427 
of  external  nose,  324 
of  septum,  206,  324 
Frontal  sinus,  1 16 

acute  inflammation  of,  137 
chronic  inflammation  of,  137 
operations  upon,  142,  153 
Frost-bites  of  ear,  426 
Furuncles  in  meatus  of  ear,  418 
in  nasal  vestibule,  86 

G. 

Galton  whistle,  400 
Galvanocaustic  apparatus,  75,  76 
Gelle's  test,  401 
Globus  hystericus,  240 
Goiter,  exophthalmic,  reflex  nasal, 
340 

H. 
Habits,  influence  of,  on  nasal  and 

pharyngeal  diseases,  48 
Hammer,  360 
Hay-fever,  272 
Hearing,  acuity  of,  396 

tests,  398 
Hemorrhage  from  the  ear,  427 

from  the  nose,  79,  220 
Heredity,   influence  of,    upon  ear 
diseases,  393 
in  nasal  diseases,  47 


Herpes  of  pharynx,  310 

zoster,  311 
Hysterical  deafness,  537 

mimicry   of    Meniere's   disease, 
529 

I. 

Illumination  of  ear,  403 

of  nose  and  throat,  54 
Influenza,  310 

otitis,  475 
Injuries  of  ear,  427 

of  nose,  324 
Instruments,  sterilization  of,  81 
Internal  ear,  anatomy  of,  370 

diseases  of,  526 
lodism,  312 

J. 

Jugular  vein,  phlebitis  of,  523,  525 


Labyrinth,  370.     See  also  Internal 
ear. 
ethmoid,  no 
of  ear,  370 

apoplexy  of,  528 
rarefaction  of  capsule  of,  457 
Lateral  sinus,  369 

thrombosis  of,  522 
Leprosy,  306 
Leukocythemia,  310 
Lingual  tonsil,   225.    See    Tonsil, 

lingual. 
Lofifler's  solution,  70,  291 
Lumbar  puncture,  diagnostic,  515 
Luschka's  tonsil,  225.     See  Tonsil, 
pharyngeal. 

M. 

Maggots  in  nose,  323 
Malleus,  360 
Massage  in  ozena,  162 

pneumatic,  of  ear,  406 
Mastoid  abscess,  478,  479,  481 

antrum,  366 

operation,  481,  499 

subperiosteal  abscess,  478,  481 


544 


INDEX. 


Mastoiditis,  476 
results  of,  477 
Maxillary  sinus,  120 

acute  inflammation  of,  125 
chronic  inflammation  of,  126 
cysts  of,  135 
operations  upon,  131 
translumination  of,  129 
Measles,  308 

influence  upon  ear,  390,  462,  466 
Meatus,  external,  of  ear,  anatomy 
of.  348 
at  birth,  351 
diffuse  inflammation  of,  417 
foreign  bodies  in,  423 
furuncles  of,  418 
mycosis  of,  419 
occlusion  of,  425 
operative  detachment  of,  424 
internal,  372 
Membrana  tympani,  anatomy   of, 

354 
morbid  appearance  of,  404 
normal  appearance  of,  402 
paracentesis  of,  412,  453 
perforations  in,  405 
ruptures  of,  427 
Meniere's  disease,  528 

symptoms,  529 
Meningitis,  cerebrospinal,  533 
of  otitic  origin,  514,  520 
serous,  521 
Menthol,  74 

Middle  ear,  adhesive  inflammation 
of,  442 
operations  on,  453 
sclerosis  of,  457 
serous  or  exudative  catarrh  of, 

441 
syphilitic  catarrh  of,  441 
turbinal,  resection  of,  106 
Mouth-breathing,  52,  195 
Mucocele,  100.     See  Sinuitis. 
Mumps,  532 
Myringitis,  427 

N. 

Nasal  douche,  66 
danger  of,  67 


Nasal  hemorrhage,  220 

hydrorrhea,  222 

mucous  membrane,  30,  31 

papillomata,  192 

passages,  anatomy  of,  20-26 
cavernous  tissue  in,  32,  33 
development  of,  17,  18 
disease,  influence  of,  upon  ear, 

387 
external  wall  of,  23 
infantile,  19 
nerves  of,  35 
obstruction  of,  51 
occlusion  of,  198 
physiology  of,  36,  37 
polypi,  187 
secretions,  52 
stenosis,  194 
synechise,  197 
wounds,  antisepsis  of,  83 
Necrosis  of  bone  in  middle  ear,  506 

syphilitic,  of  nose,  297 
Neuroses,  nasal,  332 
Nirvanin,  72 
Nose,  adenoma  of,  317 
bridge  of,  20 
cancer  of,  317 
chondroma  of,  316 
cysts  of,  315 
fibroma  of,  315 
foreign  bodies  in,  322 
fractures  of,  324 
hemorrhage  from,  79,  220 
injuries  of,  324 
irritable,  168,  171 
maggots  in,  323 
necrosis  of,  syphilitic,  297 
normal  appearances  in,  57,  58 
osteoma  of,  316 
redness  of,  86 
tuberculosis  of,  303 
tumors  of,  314 

O. 

Obstruction  of  nasal  passages,  51, 

52 
Occlusion  of  meatus  of  ear,  425 
of  nasal  passages,  198 
by  edema,  185 


INDEX. 


545 


Odor  in  chronic  purulent  otitis,  488, 
491 
of  nasal  secretions,  53 
Olfactory  nerve,  distribution  of,  35 
Orthoform,  77 
Ossicles  of  drum,  359 

removal  of,  454 
Ossiculectomy,  454 
Osteoma  in  chronic  purulent  otitis, 
498 
of  nose,  316 
Otalgia,  512 

Otitis  media,  acute  purulent,  465 
chronic  purulent,  488 

with  retention  of  pus,  491 
of  influenza,  475 
of  nurshngs,  461 
simple,  461,  463 
Otomycosis,  419 
Ozena,  155 

simulated  by  ethmoid  suppura- 
tion, 145 
syphilitic,  300 
treatment  of,  160 

P. 

Papillomata  in  pharynx,  319 

nasal,  192,  313 
Paralysis,  facial,  in  ear  disease,  510 
Parasites,  animal,  in  nose,  323 
Perichondritis  of  auricle,  416 
Pharyngeal  bursa,  246 

tonsil,  225.    See  Tonsil,  pharyn- 


Pharyngitis,  acute,  232 

chronic,  238 

granular,  238 

sicca,  247 

suppurative,  244 
Pharyngomycosis,  243 
Pharynx,  anatomy  of,  27,  28,  29 

at  birth,  20 

blood-vessels  of,  33 

cancer  of,  320 

cicatrices  in,  326 

development  of,  18 

fibroma  of,  318 

herpes  of,  310 

mucous  membrane  of,  30 
35 


Pharynx,  nerves  of,  35 

normal  appearances  in,  59-66 

physiology  of.  38,  39 

tuberculosis  of,  303 

tumors  of,  318 
Phlebitis  of  lateral  sinus,  514,  522 
Physiology  of  hearing,  376 

of  semicircular  canals,  380 
Plugs,  cerumen,  in  ear,  420 

epidermis,  in  ear,  421 
Pneumatic  massage  of  ear,  406 
Politzer's  inflation  of  ear,  408 
Polypi  in  ear,  505 

nasal,  187,  313 
Polypus,  bleeding,  of  septum,  314 
Promontory  of  drum  cavity,  358 
Prussak's  space,  362 
Pyemia  of  otitic  origin,  522 

Q. 

Quinin,  influence  of,  upon  ear,  532 
Quinsy,  234 

R. 

Radical  (mastoid)  operation,  499 
Rarefaction   of    capsule    of    laby- 
rinth, 457 
Reflex  neuroses,  332 
Retropharyngeal  abscess,  236 
Rheumatic  sore  throat,  312 
Rheumatism,  311 
Rhinitis,  acute  purulent,  86 

caseosa,  95 

chronic,  93 

diphtheritic,  167 

dry  anterior,  163 

hypertrophic,  177 
treatment  of,  182 

membranous,  166 

purulent,  of  children,  98 

simple  chronic,  177 

subacute,  of  scrofulous  children, 
98 
Rhinoscleroma,  306 
Rhinoscopy,  anterior,  56 

posterior,  64 
Rinne's  test,  400 
Rose-cold,  273 
Rosenmiiller's  fossa,  29 


546 


INDEX. 


Sacculus,  373 

Salicylates,  influence  of,  upon  ear, 

532 
Scarlet  fever,  308 

influence  of,  upon  ear,  390,  462, 
466 
Sclerosis  of  middle  ear,  457 
Scrofulosis,  305 
and  enlarged  pharyngeal  tonsil, 
256 
Secretions,  nasal,  52 
Septicemia  of  otitic  origin,  522 
Septum,  nasal,  200 
abscess  of,  165 
anatomy  of,  200 
asymmetry  of,  202 
crests  upon,  204 
deformities  of,  208 
fracture  of,  206,  324 
hematoma  of,  165 
hypertrophies  on,  181 
operations  upon,  210-219 
polypus  of,  314 
resection  of,  213 
ulcer  of,  164 
Sinuitis,  complications  of,  102 
diagnosis  of,  105 
ethmoid,  144 
etiology  of,  104 
frontal,  116 
in  general,  loi 
maxillarj',  125 

treatment  of,  106 
pathology  of,  103 
sphenoid,  150 
Sinus,  frontal,  1 16 

inflammation  of,  137 
operations  upon,  142,  153 
lateral,  369 

thrombosis  of,  522 
maxillary,  120 
sigmoid,  369 
thrombosis,  522 
Skull,  fracture  at  base  of,  427 
Small-pox,  309 
Snare  for  the  ear,  306 
galvanocaustic,  79 
nasal,  "j"],  78 


Sneezing,  53 

fits,  171,  335 
Sound,  Belloc's,  80 
Sounds,  conduction  of,  379,  400 
Specula,  nasal,  55,  56 
Speculum,  aural,  403 

Siegle's,  406 
Sphenoid  sinus,  117 

inflammation  of,  150 
operation  upon,  151 
Sprays,  68,  69 
Stapes,  3C0 

ankylosis  of,  459 
Static  sense,  38 
Stenosis,  nasal,  194 

of  Eustachian  tube,  446 

of  meatus  of  ear,  425 
Sterilization  of  cotton  swabs,  82 

of  instruments,  81 
Sterilizer,  81 
Suprarenal  solution,  73 
Synechiae  in  nose,  197 
Syphilis  of  air-passages,  293 

of  internal  ear,  533 

of  middle  ear,  441 


T. 

Tabes,  ear  affections  in,  536 
Teeth,  influence  of,  upon  ear,  392 
Tensor  tympani  muscle,  353.     See 
Tytnpanic  cavity. 
tenotomy  of,  455 
Throat,  rheumatic  sore,  312 
Thrombosis  of  lateral  sinus,  522 
Tinnitus;  395 
Tobacco,  influence  of,  upon  throat, 

47.  239 
Tone-series,    Bezold's    continuous, 

398 
Tonsil,  faucial,  anatomy  of,  224 
hypertrophy  of,  264 
inflammation  of,  acute,  226 
chronic,  238 
lingual,  225 

inflammation  of,  231 
phlegmonous  inflammation  of, 

235 
pharyngeal,  225 


INDEX. 


547 


Tonsil,  pharyngeal,  hypertrophy  of, 
249 
inflammation  of,  232 
operations  upon,  259 
Tonsillar  concretions,  238 
Tonsillitis,  acute,  226 

chronic,  238 
Translumination  of  maxillary  sinus, 

129 
Trichloracetic    acid,    cauterization 

with,  74 
Tuberculosis  of  middle  ear,  510 

of  nose  and  pharynx,  303 
Tumors  of  ear,  425 
of  nose,  313 
of  pharynx,  318 
Turbinated    process,    anatomy   of, 

24,  58,  108,  113 
Turbinectomy,  184 
Tympanic     cavity,     anatomy     of, 

353 
Typhoid  fever,  309 

as  cause  of  ear  disease,  391 


U. 

Umbo,  360 

Uncinate  process,  iii 
Utriculus,  373 
Uvula,  28 
edema  of,  223 

V. 

Valsalva's  experiment,  379 
Varicose  veins  in  pharynx,  239 
Vegetations,  adenoid,  249,  258 
Vein,  jugular,  phlebitis  of,  523,  525 
Vertigo  from  ear  disease,  395 

from  semicircular  canals,  384 
Vestibule  of  internal  ear,  37 

nasal  diseases  of,  85 
Voice  in  adenoid  vegetations,  250 

W. 

Weber's  test,  401 
Whistle,  Galton's,  400 
Wilde's  incision,  481 


Catalog'ue  S!e  Medical  Publications 


OF 


W.  B.  SAUNDERS  6  COMPANY 

PHILADELPHIA       x  ii  W  )(  y  y  LONDON 

925  Walnut  Street        y  W  !K  K      9>  Henrietta  Street.  Covent  Garden 

Arranged  Alphabetically  and  Classified  under  Subjects 

See     page      22     for     a     List     of     Contents     cle^sified     according     to     subjects 


THE  books  advertised  in  this  Catalogfue  as  being  so/d  by  subscription  are  usually  to  be  ob- 
tained from  travelling  solicitors,  but  they  will  be  sent  direct  from  the  office  of  publication 
(charges  of  shipment  prepaid)  upon  receipt  of  the  prices  given.     All  the  other  books 
advertised  are  commonly  for  sale  by  booksellers  in  all  parts  of  the  United  States ;  but  books 
vill  be  sent  to  any  address,  carriage  prepaid,  on  receipt  of  the  published  price. 

Money  may  be  sent  at  the  risk  of  the  publisher  in  either  of  the  following  ways:  A  postal 
money  order,  an  express  money  order,  a  bank  check,  and  in  a  registered  letter.  Money  sent 
in  any  other  way  is  at  the  risk  of  the  sender. 

SPECIAL  To  physicians  of  approved  credit  books  will  be  sent,  post-paid,  on  the  following 
OFFER  terms :  ^5.00  cash  upon  delivery  of  books,  and  monthly  payments  of  $5.00  there- 
after until  full  amount  is  paid.  Any  one  or  two  volumes  will  be  sent  on  thirty  days'  time  to 
those  who  do  not  care  to  make  a  large  purchase. 


An  American  Text-Book  cf  Applied  Therapeutics. 

Edited  by  James  C.  Wilson,  M.  D.,  Professor  of  Practice  of  Medicine 
and  of  Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia. 
Handsome  imperial  octavo  volume  of  1326  pages.  Illustrated.  Cloth, 
$7.00  net ;  Sheep  or  Half  Morocco,  ^8.00  net. 

An  American  Text-Book  ^  the  Diseases  of  Children. 

Second  Edition,  Revised. 

Edited  by  Louis  Starr,  M.  D.,  Consulting  Pediatrist  to  the  Maternity 
Hospital,  etc.  ;  assisted  by  Thompson  S.  Westcott,  M.  D.,  Attending 
Physician  to  the  Dispensary  for  Diseases  of  Children,  Hospital  of  the 
University  of  Pennsylvania.  Handsome  imperial  octavo  volume  of 
1244  pages,  profusely  illustrated.  Cloth,  ^7.00  net;  Sheep  or  Half 
Morocco,  ^8.00  net. 

An  American  Text- Book  qf  Diseases  qf  the  Eye,  Ear, 
Nose,  and  Throat. 

Edited  by  G.  E.  de  Schweinitz,  M.  D.,  Professor  of  Ophthalmology, 
Jefferson  Medical  College,  Philadelphia ;  and  B.  Alexander  Randall, 
M.  D.,  Clinical  Professor  of  Diseases  of  the  Ear,  University  of  Penn- 
sylvania. Imperial  octavo  of  125 1  pages;  766  illustrations,  59  of  them 
in  colors.     Cloth,  $7.00  net;  Sheep  or  Half  Morocco,  ^8.00  net. 


MEDICAL  PUBLICATIONS 


An  American  Text-Book  qf  Genito-Urinary  Diseases, 
Syphilis,  an^  Skin  Diseases. 

Edited  by  L.  Bolton  Bangs,  M.  D.,  Professor  of  Genito-Urinary  Sur- 
gery, University  and  Bellevue  Hospital  Medical  College,  New  York  ; 
and  W.  A.  Hardaway,  M.  D.,  Professor  of  Diseases  of  the  Skin  and 
Syphilis,  Washington  University,  St.  Louis.  Imperial  octavo  volume  of 
1229  pages,  with  300  engravings  and  20  full-page  colored  plates.  Cloth, 
$7.00  net;  Sheep  or  Half  Morocco,  $8.00  net. 

An  American  Text-Book  qf  Gynecology,  Medical  and 

Surgical.       second  Edition,  Revised. 

Edited  by  J.  M.  Baldy,  M.  D.,  Professor  of  Gynecology,  Philadelphia 
Polyclinic,  etc.  Handsome  imperial  octavo  volume  of  718  pages;  341 
illustrations  in  the  text,  and  38  colored  and  half-tone  plates.  Cloth, 
56.00  net;  Sheep  or  Half  Morocco,  $7.00  net. 

An  American  Text-Book  qf  Legal  Medicine  and  Toxi- 
cology. 

Edited  by  Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Nervous 
Department,  College  of  Physicians  and  Surgeons,  New  York;  and 
Walter  S.  Haines,  M.  D.,  Professor  of  Chemistry,  Phannacy,  and 
Toxicology,  Rush  Medical  College,  Chicago.     /;/  Preparation. 

An  American  Text-Book  qf  Obstetrics,    second  Edition. 

Thoroughly  Revised  and  Enlzkrged.     In  Two  Volumes. 

Edited  by  Richard  C.  Norris,  M.  D.  ;  Art  Editor,  Robert  L.  Dick- 
inson, M.  D.  Two  handsome  imperial  octavo  volumes  of  about  600 
pages  each  ;  nearly  500  illustrations  and  a  large  number  of  colored 
plates.  Per  set :  Cloth,  $0.00  net;  Sheep  or  Half  Morocco,  j;o.oonet. 
Ready  Soon. 

An  American  Text-Book  qf  Pathology. 

Edited  by  Ludvig  Hektoen,  M.  D.,  Professor  of  Pathology  in  Rush 
Medical  College,  Chicago;  and  David  Riesman,  M.  D.,  Demonstrator 
of  Pathologic  Histology  in  the  University  of  Pennsylvania.  Imperial 
octavo  of  1245  pages,  443  illustrations,  66  in  colors.  Cloth,  $7.50 
net;  Sheep  or  Half  Morocco,  S8.50  net.     By  Subscription. 

An  American  Text-Book  qf  Physiology,    second  Edition, 

Revised,  in  Two  Volinnes. 

Edited  by  William  H.  Howell,  Ph.  D.,  M.  D.,  Professor  of  Physi- 
ology, Johns  Hopkins  University,  Baltimore,  Md.  Two  royal  octavo 
volumes  of  about  600  pages  each.  Fully  illustrated.  Per.  volume: 
Cloth,  $3.00  net;    Sheep  or  Half  Morocco,  $3.75  net. 

An  American  Text-Book  qf  Surgery.    Third  Edition. 

Edited  by  William  W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.);  and 
J.  William  White,  M.  D.,  Ph.D.  Handsome  octavo,  1230  pages; 
496  wood-cuts  and  37  colored  and  half-tone  plates.  Thoroughly  revi.sed 
and  enlarged,  with  a  section  devoted  to  "The  Use  of  the  Rontgen 
Rays  in  Surger}'. ' '    Cloth,  $7.00  net ;  Sheep  or  Half  Morocco,  $8.00  net. 


OF  W.  B.  SAUNDERS  or  CO. 


An  American  Text- Book  of  Theory  and  Practice  of 
Medicine. 

Edited  by  the  late  William  Pepper,  M.  D.,  LL.  D.,  Professor  of  the 
Theory  and  Practice  of  Medicine  and  of  Clinical  Medicine,  University 
of  Pennsylvania.  Two  handsome  imperial  octavos  of  about  looo  pages 
each.  Illustrated.  Per  volume:  Cloth,  $5.00  net;  Sheep  or  Half 
Morocco,  $6.00  net. 

GET  THE  BEST  THE  NEW  STANDARD 

The  American  Illustrated  Medical  Dictionary. 

Second  Exlition,  Revised. 

For  Practitioners  and  Students.  A  Complete  Dictionary  of  the  Terms 
used  in  Medicine,  Surgery,  Dentistry,  Pharmacy,  Chemistry,  and  the 
kindred  branches,  including  much  collateral  information  of  an  encyclo- 
pedic character,  together  with  new  and  elaborate  tables  of  Arteries, 
Muscles,  Nerves,  Veins,  etc.  ;  of  Bacilli,  Bacteria,  Micrococci,  Strepto- 
cocci ;  Eponymic  Tables  of  Diseases,  Operations,  Signs  and  Symptoms, 
Stains,  Tests,  Methods  of  Treatment,  etc.,  etc.  By  W.  A.  Newman 
DoRLAND,  A.M.,  M.  D.,  Editor  of  the  "American  Pocket  Medical 
Dictionary."  Handsome  large  octavo,  nearly  800  pages,  bound  in 
full  flexible  leather.     Price,  $4.50  net;   with  thumb  index,  $5.00  net. 

Gives  a  Mziximum  Amount  of  Matter  in   a   Minimum   Space   and   at  the  Lowest 

Possible  Cost. 

This  Edition  contains  all  the  Latest  Words. 

"  I  must  acknowledge  my  astonishment  at  seeing  how  much  he  has  condensed  within 
relatively  small  space.  I  find  nothing  to  criticise,  very  much  to  commend,  and  was  interested 
in  finding  some  of  the  new  words  which  are  not  in  other  recent  dictionaries." — ROSWELL  PARK, 
Professor  of  Principles  and  Practice  of  Surgery  and  Clinical  Surgery,  University  of  Buffalo. 

"  I  congratulate  you  upon  giving  to  the  profession  a  dictionary  so  compact  in  its  structure, 
and  so  replete  with  information  required  by  the  busy  practitioner  and  student.  It  is  a  necessity 
as  well  as  an  informed  companion  to  every  doctor.  It  should  be  upon  the  desk  of  every  prac- 
titioner and  student  of  medicine." — JOHN  B.  MURPHY,  Professor  of  Surgery  and  Clinical 
Surgery,  Northwestern  University  Medical  School,  Chicago. 

The  American  Pocket  Medical  Dictionary.    ^^  ?^°"' 

'  Revued. 

Edited  by  W.  A.  Newman  Dorland,  M.  D.,  Assistant  Obstetrician  to 
the  Hospital  of  the  University  of  Pennsylvania ;  Fellow  of  the  Amer- 
ican Academy  of  Medicine.  Containing  the  pronunciation  and  defini- 
tion of  the  principal  words  used  in  medicine  and  kindred  sciences,  with 
64  extensive  tables.  Handsomely  bound  in  flexible  leather,  with  gold 
edges.     Price  $1.00  net;  with  thumb  index,  $1.25  net. 

The  American  Year-Book  of  Medicine  on?  Surgery. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  Foreign  authors  and  investi- 
gators. Arranged  with  critical  editorial  comments,  by  eminent  Amer- 
ican specialists,  under  the  editorial  charge  of  George  M.  Gould,  M.  D. 
Year-Book  of  1902  in  two  volumes — Vol.  I.  including  General  Medicine; 
Vol.  II.,  General  Surgery.  Per  volume :  Cloth,  $3.00  net;  Half  Mo- 
rocco, $3.75  net.     Sold  by  Subscription. 


MEDICAL  PUBLICATIONS 


Abbott  on  Transmissible  Diseases,    second  Edition.  Revised. 

The  Hygiene  of  Transmissible  Diseases :  their  Causation,  Modes  of 
Dissemination,  and  Methods  of  Prevention.  By  A.  C.  Abbott,  M.  D., 
Professor  of  Hygiene  and  Bacteriology,  University  of  Pennsylvania, 
Octavo,  351  pages,  with  numerous  illustrations.     Cloth,  $2.50  net. 

Anders'  Practice  qf  Medicine.       Fifth  Revised  edition. 

A  Text-Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Hand- 
some octavo  volume  of  1297  pages,  fully  illustrated.  Cloth,  ^5.50  net; 
Sheep  or  Half  Morocco,  $6.50  net. 

Bastin's  Botany. 

Laboratory  Exercises  in  Botany.  By  Edson  S.  Bastin,  M.  A.,  late 
Professor  of  Materia  Medica  and  Botany,  Philadelphia  College  of 
Pharmacy.     Octavo,  536  pages,  with  87  plates.     Cloth,  $2.00  net. 

Beck  on  Fractures. 

Fractures.  By  Carl  Beck,  M.  D.,  Professor  of  Surgery,  New  York 
Post-graduate  Medical  School  and  Hospital.  With  an  appendix  on  the 
Practical  Use  of  the  Rontgen  Rays.  335  pages,  170  illustrations. 
Cloth,  $3.50  net. 

Beck's  Surgical  Asepsis. 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.  D.,  Professor  of 
Surgery,  New  York  Post-graduate  Medical  School  and  Hospital.  306 
pages;  65  text-illustrations  and  12  full-page  plates.     Cloth,  $1.25  net. 

Sergey's  Principles  of  Hygiene. 

The  Principles  of  Hygiene  :  A  Practical  Manual  for  Students,  Physi- 
cians, and  Health  Officers.  By  D.  H.  Bergey,  A.  M.,  M.  D.,  First 
Assistant,  Laboratory  of  Hygiene,  University  of  Pennsylvania.  Hand- 
some octavo  volume  of  495  pages,  illustrated.     Cloth,  ^3.00  net. 

Boisliniere's    Obstetric  Accidents,   Emergencies,  anb 
Operations. 

Obstetric  Accidents,  Emergencies,  and  Operations.  By  L.  Ch.  Bois- 
LINIERE,  M.  D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis  Medical 
College.     381  pages,  handsomely  illustrated.     Cloth,  $2.00  net. 

Bohm,  Davidoff,  and  Ruber's  Histology. 

A  Text-Book  of  Human  Histology.  Including  Microscopic  Technic. 
By  Dr.  A.  A,  Bohm  and  Dr.  M.  von  Davidoff,  of  Munich,  and 
G.  Carl  Huber,  M.  D.,  Junior  Professor  of  Anatomy  and  Director  of 
Histological  Laboratory,  University  of  Michigan.  Handsome  octavo 
of  503  pages,  with  351  beautiful  original  illustrations.     Cloth,  $3.50  net. 


OF  W.  B.  SAUNDERS  ^  CO. 


Brower  and  Bannister's  Manual  of  Insanity. 

A  Practical  Manual  of  Insanity.  For  the  Student  and  General  Practi- 
tioner. By  Daniel  R.  Brower,  A.  M.,  M.  D.,  LL.D.,  Professor  of 
Nervous  and  Mental  Diseases  in  Rush  Medical  College,  in  Affiliation 
with  the  University  of  Chicago,  and  in  the  Post-Graduate  Medical 
School,  Chicago;  and  Henry  M.  Bannister,  A.M.,  M.  D.,  formerly 
Senior  Assistant  Physician,  Illinois  Eastern  Hospital  for  the  Insane. 
Handsome  octavo,  426  pages,  with  13  full-page  inserts.    Cloth,  $3.00  net. 

Butler's  Materia  Medica,  Therapeutics,  and  Pharma- 
cology.     Fourth  Edition.  Revised  and  Enlzo-ged. 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharmacology. 
By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  of  Materia  Medica  and 
of  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago. 
Octavo,  896  pages,  illustrated.  Cloth,  $4.00  net;  Sheep  or  Half  Mo- 
rocco, $5.00  net. 

Chapin  on  Insanity. 

A  Compendium  of  Insanity.  By  John  B.  Chapin,  M.  D.,  LL.  D., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane  ;  Honorary 
Member  of  the  Medico-Psychological  Society  of  Great  Britain,  of  the 
Society  of  Mental  Medicine  of  Belgium,  etc.  121110,  234  pages,  illus- 
trated.    Cloth,  $1.25  net. 

Chapman's   Medical    Jurisprudence  and  Toxicolo^. 

Second  Edition,  Revised. 

Medical  Jurisprudence  and  Toxicology.  By  Henry  C.  Chapman, 
M.  D.,  Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence, 
Jefferson  Medical  College  of  Philadelphia.  254  pages,  with  55  illus- 
trations and  3  full-page  plates  in  colors.     Cloth,  $1.50  net. 

Church  and  Peterson's  Nervous  and  Mental  Diseases. 

Third  Edition,  Revised  and  Enlarged. 

Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.  D.,  Pro- 
fessor of  Nervous  and  Mental  Diseases,  and  Head  of  the  Neurological 
Department,  Northwestern  University  Medical  School,  Chicago;  and 
Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Department, 
College  of  Physicians  and  Surgeons,  New  York.  Handsome  octavo 
volume  of  875  pages,  profusely  illustrated.  Cloth,  ^5.00  net;  Sheep  or 
Half  Morocco,  $6.00  net. 

Clarkson's  Histolo|(y. 

A  Text-Book  of  Histology,  Descriptive  and  Practical.  By  Arthur 
Clarkson,  M.  B.,  C.  M.  Edin.,  formerly  Demonstrator  of  Physiology 
in  the  Owen's  College,  Manchester;  late  Demonstrator  of  Physiology 
in  Yorkshire  College,  Leeds.  Large  octavo,  554  pages;  22  engravings 
and  174  beautifully  colored  original  illustrations.     Cloth,  $4.00  net. 

Corwin's  Physical  Diagnosis.    Third  Edition,  Revised. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  Arthur  M. 
CoRWiN,  A.  M.,  M.  D.-,  late  Instructor  in  Physical  Diagnosis  in  Rush 
Medical  College,   Chicago.     219  pages,  illustrated.     Cloth,  $1.25  net. 


MEDICAL  PUBLICATIONS 


Crothers'  Morphinism  arid  Narcomania. 

Morphinism  and  Narcomania  from  Opium,  Cocain,  Ether,  Chloral, 
Chloroform,  and  other  Narcotic  Drugs ;  also  the  Etiology,  Treatment, 
and  Medicolegal  Relations.  By  T.  D.  Crothers,  ]\I.  D.,  Superin- 
tendent of  Walnut  Lodge  Hospital,  Hartford,  Conn.  ;  Professor  of 
Mental  and  Ner\ous  Diseases,  New  York  School  of  Clinical  Medicine, 
etc.     Handsome  i2mo  of  351  pages.     Cloth,  $2.00  net. 

DaCosta'S    Surgery.       Third  Edition.  Revised. 

Modem  Surgery,  General  and  Operative.  By  John  Chalmers  Da 
Costa,  M.  D.,  Professor  of  Principles  of  Surgery  and  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia;  Surgeon  to  the  Philadelphia 
Hospital,  etc.  Handsome  octavo  volume  of  11 17  pages,  profusely 
illustrated.     Cloth,  $5.00  net;   Sheep  or  Half  Morocco,  $6.00  net. 

Enlarged  by  over  200  Pages,  with  more  than  100  New  Illustrations. 

Davis's  Obstetric  Nursing. 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M., 
M.  D.,  Professor  of  Obstetrics,  Jefferson  Medical  College  and  Phila- 
delphia Polyclinic ;  Obstetrician  and  Gynecologist,  Philadelphia  Hos- 
pital,     i2rao,  400  pages,  illustrated.     Crushed  Buckram,  $1.75  net. 

DeSchweinitz  on  Diseases  cf  the  Eye.      Fourth  Edition. 

Entirely  Reset :  Thoroughly  Revised  and  Enleirged. 

Diseases  of  the  Eye.  A  Handbook  of  Ophthalmic  Practice.  By  G. 
E.  DE  ScHWEiNiTZ,  M.  D.,  Profcssor  of  Ophthalmology,  Jefferson  Medi- 
cal College,  Philadelphia,  etc.  Handsome  royal  octavo  volume  of  750 
pages ;  300  fine  illustrations  and  6  full-page  chromo-lithographic  plates. 
Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  §6.00  net. 

Dorland's  Dictionaries. 

[See  American  Illustrated  Medical  Dictionary  and  American 
Pocket  Medical  Dictionary  on  page  3.] 

Dorland*S    Obstetrics.       second  sedition.  Revised  and  Greatly  Enlarged. 

Modem  Obstetrics.  By  W.  A.  Newman  Dorland,  M.  D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania;  Associate  in 
Gynecology,  Philadelphia  Polyclinic.  Octavo  volume  of  797  pages, 
with  201  illustrations.     Cloth,  $4.00  net. 

£ichhorst's  Practice  cf  Medicine. 

A  Text-Book  of  the  Practice  of  Medicine.  By  Dr.  Hermann  Eich- 
HORST,  Professor  of  Special  Pathology  and  Therapeutics  and  Director 
of  the  Medical  Clinic,  University  of  Zurich.  Translated  and  edited  by 
Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Phila- 
delphia Polyclinic.  Two  octavo  volumes  of  600  pages  each,  over  150 
illustrations.  Prices  per  set :  Cloth,  $6.00  net ;  Sheep  or  Half  Morocco, 
$7.50  net. 


OF  W.  B.  SAUNDERS  ^  CO. 


Eyre's  Bacteriologic  Technique. 

Bacteriologic  1  echnique.  A  Laboratory  Guide  for  the  Medical,  Dental, 
and  Technical  Student.  By  J.  W.  H.  Evre,  M.  D.,  F.  R.  S.,  Edin., 
Lecturer  on  Bacteriology  and  Joint  Lecturer  on  Practical  Public  Health, 
Charing  Cross  Hospital  Medical  School ;  Bacteriologist  to  Charing 
Cross  and  to  St.  Mary's  Hospital  for  Sick  Children,  Plaistow.  Hand- 
some octavo,  350  pages,  with  150  illustrations.     Cloth,  $0.00  net. 

Priedrich  and  Curtis  on  the  Nose,  Throat,  and  Ear. 

Rhinology,  Laryngology,  and  Otology,  and  Their  Significance  in  Gen- 
eral Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited  by  H. 
HoLBROOK  Curtis,  M.  D.,  Consulting  Surgeon  to  the  New  York  Nose 
and  Throat  Hospital.     Octavo,  348  pages.     Cloth,  ;$2.5o  net. 

Frothin^ham's  Guide  for  the  Bacteriologist. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Frothingham, 
M.  D.  v..  Assistant  in  Bacteriology  and  Veterinary  Science,  Sheffield 
Scientific  School,  Yale  University.     Illustrated.     Cloth,  75  cts.  net. 

Galbraith  on  the  Four  Epochs  <2f  Woman's  Life. 

The  Four  Epochs  of  Woman's  Life :  A  Study  in  Hygiene.  By  Anna 
M.  Galbraith,  M.  D.,  Author  of  "Hygiene  and  Physical  Culture 
for  Women";  Fellow  of  the  New  York  Academy  of  Medicine,  etc. 
With  an  Introductory  Note  by  John  H.  Musser,  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsylvania.  i2mo  volume  of  200 
pages.     Cloth,  ^1.25  net. 

Garri^ues'  Diseases  (jf  Women.    Third  Edition.  Revised. 

Diseases  of  Women.  By  Henry  J.  Garrigues,  A.  M.,  M.  D.,  Gyne- 
cologist to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New 
York  City.  Octavo,  756  pages,  with  367  engravings  and  colored  plates. 
Cloth,  $4.50  net;  Sheep  or  Half  Morocco,  $5.50  net. 

Gorham's  Bacteriology. 

A  Laboratory  Course  in  Bacteriology.  By  F.  P.  Gorham,  M.  A., 
Assistant  Professor  in  Biology,  Brown  University.  i2mo  volume  of 
192  pages,  97  illustrations.     Cloth,  $1.25  net. 

Gould  and  Pyle*s  Curiosities  qf  Medicine. 

Anomalies  and  Curiosities  of  Medicine.  By  George  M.  Gould,  M.D., 
and  Walter  L.  Pyle,  M.  D.  An  encyclopedic  collection  of  rare  arid 
extraordinary  cases  and  of  the  most  striking  instances  of  abnormality  in 
all  branches  of  Medicine  and  Surgery,  derived  from  an  exhaustive 
research  of  medical  literature  from  its  origin  to  the  present  day, 
abstracted,  classified,  annotated,  and  indexed.  Handsome  octavo 
volume  of  968  pages;  295  engravings  and  12  full-page  plates.  Popular 
Edition.      Cloth,  $3.00  net;  Sheep  or  Half  Morocco,  $4-00  net. 

Gradle  on  the  Nose.  Throat,  and  Ear. 

Diseases  of  the  Nose,  Throat,  and  Ear.  By  Henry  Gradle,  M.  D., 
Professor  of  Ophthalmology  and  Otology,  Northwestern  University 
Medical  •  School,  Chicago.  Octavo,  547  pages,  illustrated,  including 
2  full-page  colored  plates.     Cloth,  $3.50  net. 


8  MEDICAL  PUBLICATIONS 

Grafstrom's  Mechano-Therapy. 

A  Text-Book  of  Mechano-Therapy  fMassage  and  Medical  Gymnastics). 
By  Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  late  House  Physician,  City  Hos- 
pital, Blackwell's  Island,  X.  Y.    1 2mo,  139  pages,  illustrated.    Si-oonet. 

Grant's  Surgical  Diseases  of  Face,  Mouth,  and  Jaws. 

For  Dental  Students. 

A  Text-Book  of  Surgical  Patholog}'  and  Surgical  Diseases  of  the  Face, 
Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace  Grant, 
A.  M.,  M.  D.,  Professor  of  Surgical  Pathology  and  Oral  Surgery,  Louis- 
ville College  of  Dentistry ;  Professor  of  Surgery  and  Clinical  Surgery, 
Hospital  College  of  Medicine,  Louisville.  Octavo  volume  of  215 
pages,  with  60  illustrations.     Cloth,  ^0.00  net. 

Griffith    on    the    Baby.       second  Edition,  Revised. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.  D.,  Clinical 
Professor  of  Diseases  of  Children,  University  of  Pennsylvania;  Phy- 
sician to  the  Children's  Hospital,  Philadelphia,  etc.  i2mo,  404  pages; 
67  illustrations  and  5  plates.     Cloth,  $1.50  net. 

Griffith's  Weight  Chart 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania. 
25  charts  in  each  pad.     Per  pad,  50  cts.  net. 

Haynes*  Anatomy. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.  D.,  Professor  of 
Practical  Anatomy  in  Cornell  University  Medical  College.  680  pages ; 
42  diagrams  and  134  full -page  half-tone  illustrations  from  original  photo- 
graphs of  the  author's  dissections.     Cloth,  $2.50  net. 

Heisler'S    EmbryolO^.       second  Edition.  Revised. 

A  Text-Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Professor 
of  Anatomy,  Medico-Chirurgical  College,  Philadelphia.  Octavo  volume 
of  405  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

HirsfS    Obstetrics.       TWrd  Edition.  Revised  and  Enlarged. 

A  Text-Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D.,  Professor 
of  Obstetrics,  University  of  Pennsylvania.  Handsome  octavo  volume 
of  873  pages ;  704  illustrations,  36  of  them  in  colors.  Cloth,  $5.00  net ; 
Sheep  or  Half  Morocco,  $6.00  net. 

Hyde  and  Montgomery  on  Syphilis  and  the  Venereal 

Diseases.       second  Edition.  Revbed  and  Greatly  Enlarged. 

Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde,  M.  D., 
Professor  of  Skin,  Genito-Urinary,  and  Venereal  Diseases,  and  Frank 
H.  Montgomery,  M.  D.,  Associate  Professor  of  Skin,  Genito-Urinary, 
and  Venereal  Diseases  in  Rush  Medical  College,  Chicago,  111.  Octa\  o, 
594  pages,  profusely  illustrated.     Cloth,  $4.00  net. 


OF  W.  B.    SA  UNDERS  &>  CO. 


^e  International  Text- Book  of  Surgery,     in  Two  Volumes. 

Second  Edition.  Thoroughly  Revised  and  Greatly  Enlarged. 

By  American  and  British  Authors.  Edited  by  J.  Collins  Warren, 
M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medi- 
cal School,  Boston ;  and  A.  Pearce  Gould,  M.  S.,  F.  R.  C.  S.,  Lecturer 
on  Practical  Surgery  and  Teacher  of  Operative  Surgery,  Middlesex 
Hospital  Medical  School,  London,  Eng.  Vol.  I.  General  Surgery. — 
Handsome  octavo,  947  pages,  with  458  beautiful  illustrations  and  9 
lithographic  plates.  Vol.  II.  Special  or  Regional  Surgery. — Handsome 
octavo,  1072  pages,  471  text  illustrations,  and  8  lithographic  plates. 
Per  volume:  Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  ^6.00  net. 

"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  years.  The  clini- 
cian and  the  pathologist  have  joined  hands  in  its  production,  and  the  result  must  be  a  satis- 
faction to  the  editors  as  it  is  a  gratification  to  the  conscientious  reader." — Annals  of  Surgery. 

"  This  is  a  work  which  comes  to  us  on  its  own  intrinsic  merits.  Of  the  latter  it  has  very 
many.  The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different  authors 
is  equally  so.  What  is  especially  to  be  recommended  is  the  painstaking  endeavor  of  each 
yriter  to  make  his  subject  clear  and  to  the  point.  To  this  end  particularly  is  the  technique 
01  operations  lucidly  described  in  all  necessary  detail.  And  withal  the  work  is  up  to  date  in 
a  very  remarkabls  degree,  many  of  the  latest  operations  in  the  different  regional  parts  of  the 
body  being  given  in  full  details.  There  is  not  a  chapter  in  the  work  from  which  the  reader 
may  not  learn  something  new." — Medical  /Record,  New  York. 

Jackson's  Diseases  of  the  Eye. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.  M.,  M.  D., 
Emeritus  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic  and 
College  for  Graduates  in  Medicine.  lamo  volume  of  535  pages,  with 
178  illustrations,  mostly  from  drawings  by  the  author.    Cloth,  $2.50  net. 

Jelliffe  and  Diekman's  Chemistry. 

A  Text- Book  of  Chemistry.  By  Smith  Ely  Jelliffe,  M.  D.,  Ph.  D., 
Professor  of  Pharmacology,  College  of  Pharmacy,  New  York ;  and 
George  C.  Diekman,  Ph.  G.,  M.  D.,  Professor  of  Theoretical  and 
Applied  Pharmacy,  College  of  Pharmacy,  New  York.  Octavo,  550 
pages,  illustrated.     Ready  Shortly. 

Heating's  Life  Insurance. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating,  M.  D., 
Fellow  of  the  College  of  Physicians  of  Philadelphia ;  Ex-President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages.     With  numerous  illustrations.     Cloth,  $2.00  net. 

Keen  on  the  Surgery  qf  Typhoid  Fever. 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.  By  Wm. 
W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  the  Principles 
of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College,  Phila- 
delphia, etc.    Octavo  volume  of  386  pages,  illustrated.   Cloth,  $3.00  net. 

Keen's    Operation    Blank.      second  Edition.  Revised  rorm. 

An  Operation  Blank,  with  Lists  of  Instruments,  etc.,  Required  in  Vari- 
ous Operations.  Prepared  by  W.  W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S. 
(Hon.),  Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia.  Price  per  pad,  blanks  for  fifty 
operations,  50  cts.  net. 

Kyle  on  the  Nose  and  Throat,    second  sedition. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D.,  Clinical 
Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical  College, 
Philadelphia.  Octavo,  646  pages;  over  150  illustrations  and  6  litho- 
graphic plates.     Cloth,  $4.00  net;  Sheep  or  Half  Morocco,  $5.00  net. 


lo  MEDICAL  PUBLICATIONS 


Laine's  Temperature  Chart. 

By  D.  T.  Laine,  M.  D.  For  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinar\'  and  Fecal  Excretions,  Food,  etc.  ;  with  the 
Brand  Treatment  of  Typhoid  Fever  on  the  back  of  each  chart.  Pad  of 
25  charts,  50  cts.  net. 

Levy,  Klemperer,  and  Eshner's  Clinical  Bacteriolo^. 

The  Elements  of  Clinical  Bacteriology.  By  Dr.  Ernst  Levy,  Pro- 
fessor in  the  University  of  Strasburg,  and  Felix  Klemperer,  Privat- 
docent  in  the  University  of  Strasburg.  Translated  and  edited  by 
Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Philadel- 
phia Polyclinic.     Octavo,  440  pages,  fully  illustrated.     Cloth,  $2.50  net. 

Lockwood's  Practice  cf  Medicine.        ReSH^d'^wS'^ed. 

A  Manual  of  the  Practice  of  Medicine.  By  George  R  oe  Lockwood, 
M.  D.,  Attending  Physician  to  Bellevue  Hospital,  New  York!  Octavo, 
847  pages,  illustrated,  including  22  colored  plates.     Cloth,  $4.00  net. 

Long's  Syllabus  cf  Gynecology. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "An  American 
Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D.,  Professor  of  Dis- 
eases of  Women  and  Children,  Medical  College  of  Virginia,  etc.  Cloth, 
interleaved,  $1.00  net. 

Macdonald's  Surgical  Diagnosis  and  Treatment. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.  D. 
Edin.,  F.  R.  C.  S.  Edin.,  Professor  of  Practice  of  Surgery  and  Clinical 
Surgery,  Hamline  University.  Handsome  octavo,  800  pages,  fully  illus- 
trated.    Cloth,  55.00  net;  Sheep  or  Half  Morocco,  ;^6.oo  net. 

Mallory  and  Wright's  Pathological  Technique. 

Second  E^tion,  Revised. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory'  Work  in 
Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on  Post- 
Mortem  Technique  and  the  Performance  of  Autopsies.  By  Frank  B. 
Mallory,  A.  M.,  M.  D.,  Assistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston;  and  James  H.  Wright,  A.M., 
M.  D.,  Instructor  in  Pathology,  Harvard  University  Medical  School, 
Boston.     Octavo,  432  pages,  fully  illustrated.     Cloth,  S3. 00  net. 

McClellan's  Anatomy  in  its  Relation  to  Art. 

Anatomy  in  its  Relation  to  Art.  An  Exposition  of  the  Bones  and 
Muscles  of  the  Human  Body,  with  Reference  to  their  Influence  upon 
its  Actions  and  External  Form.  By  George  McClellan,  M.  D., 
Professor  of  Anatomy,  Pennsylvania  Academy  of  Fine  Arts.  Hand- 
some quarto  volume,  9  by  11)^  inches.  Illustrated  with  338  original 
drawings  and  photographs ;  260  pages  of  text.  Dark  Blue  Vellum, 
$10.00  net;  Half  Russia,  $12.00  net. 

McCleIlan*S    Regional    Anatomy.       Fourth  Edition.  Revised. 

Regional  Anatomy  in  its  Relations  to  Medicine  and  Surgery.  By 
George  McClellan,  M.  D.  ,  Professor  of  Anatomy,  Pennsylvania  Acad- 
emy of  Fine  Arts.  Two  handsome  quarto  volumes,  884  pages  of  text, 
and  97  full-page  chromo-lithographic  plates,  reproducing  the  author's 
original  dissections.     Cloth,  $12.00  net^  Half  Russia,  §15.00  net. 


OF  W.  B.  SAUNDEJiS  &•  CO.  ii 

McFarland's  Pathogenic  Bacteria.    ''IS^fy^'ISo"?:?^.'" 

Text-Book  upon  the  Pathogenic  Bacteria.  By  Joseph  McFarland, 
M.  D.,  Professor  of  Pathology  and  Bacteriology,  Medico-Chirurgical 
College  of  Philadelphia,  etc.  Octavo  volume  of  621  pages,  finely 
illustrated.     Cloth,  $3.25  net. 

Mei|(s  on  Feeding  in  Infancy. 

Feeding  in  Early  Infancy.  By  Arthur  V.  Meigs,  M.  D.  Bound  in 
limp  cloth,  flush  edges,  25  cts.  net. 

Moore's  Orthopedic  Surgery. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.  D.,  Pro- 
fessor of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery,  Uni- 
versity of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo  volume 
of  356  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

Morten's  Nurses*  Dictionary. 

Nurses'  Dictionary  of  Medical  Terms  and  Nursing  Treatment.  Con- 
taining Definitions  of  the  Principal  Medical  and  Nursing  Terms  and 
Abbreviations ;  of  the  Instruments,  Drugs,  Diseases,  Accidents,  Treat- 
ments, Operations,  Foods,  Appliances,  etc.  encountered  in  the  ward  or 
in  the  sick-room.  By  Honnor  Morten,  author  of  "  How  to  Become 
a  Nurse,"  etc.     i6mo,  140  pages.     Cloth,  $1.00  net. 

Nancrede's  Anatomy  and  Dissection.    Fourth  EdHion. 

Essentials  of  Anatomy  and  Manual  of  Practical  Dissection.  By  Charles 
B.  Nancrede,  M.  D.  ,  LL.  D. ,  Professor  of  Surgery  and  of  Clinical  Sur- 
gery, University  of  Michigan,  Ann  Arbor.  Post-octavo,  500  pages,  with 
full-page  lithographic  plates  in  colors  and  nearly  200  illustrations.  Extra 
Cloth  (or  Oilcloth  for  dissection-room),  ;^2.oo  net. 

Nancrede's  Principles  cf  Surgery. 

Lectures  on  the  Principles  of  Surgery.  By  Chas.  B.  Nancrede,  M.  D., 
LL.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  University  of 
Michigan,  Ann  Arbor.   Octavo,  398  pages,  illustrated.    Cloth,  II2.50  net. 

Norris's  Syllabus  qf  Obstetrics.    TWrd  EdMon.  Revised. 

Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department  of  the 
University  of  Pennsylvania.  By  Richard  C.  Norris,  A.  M.,  M.  D., 
Instructor  in  Obstetrics  and  Lecturer  on  Clinical  and  Operative  Obstet- 
rics, University  of  Pennsylvania.  Crown  octavo,  222  pages.  Cloth, 
interleaved  for  notes,  $2.00  net. 

Ogden  on  the  Urine. 

Clinical  Examination  of  the  Urine  and  Urinary  Diagnosis.  A  Clinical 
Guide  for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Sur- 
gery. By  J.  Bergen  Ogden,  M.  D.,  Instructor  in  Chemistry,  Harvard 
Medical  School.  Handsome  octavo,  416  pages,  with  54  illustrations 
and  a  number  of  colored  plates.     Cloth,  ^^3.00  net. 

Penrose's  Diseases  qf  Women.    Fourth  Edition,  Revised. 

A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose,  M.  D., 
Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of  Penn- 
sylvania. Octavo  volume  of  539  pages,  221  illustrations.  Cloth, 
^3-75  net. 


12  MEDICAL  PUBLICATIONS 


Pye's  Bandaging. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Directions  con- 
cerning the  Immediate  Treatment  of  Cases  of  Emergency.  By  Walter 
Pye,  F.  R.  C.  S.,  late  Surgeon  to  St.  Mary's  Hospital,  London.  Small 
i2mo,  over  80  illustrations.     Cloth,  flexible  covers,  75  cts.  net. 

Pyle's  Personal  Hygiene. 

A  Manual  of  Personal  Hygiene.  Proper  Living  upon  a  Physiologic 
Basis.  Edited  by  Walter  L.  Pyle,  M.  D.,  Assistant  Surgeon  to  the 
Wills  Eye  Hospital,  Philadelphia.  Octavo  volume  of  344  pages,  fully 
illustrated.     Cloth,  $1.50  net. 

Raymond's  Physiology.     Re^^rlfAt^uyS.ed. 

A  Text-Book  of  Physiology.  By  Joseph  H.  Raymond,  A.  M.,  M.  D., 
Professor  of  Physiology  and  Hygiene  in  the  Long  Island  College 
Hospital,  and  Director  of  Physiology  in  Hoagland  Laboratory,  New 
York.     Octavo,  668  pages,  443  illustrations.     Cloth,  $3.50  net. 

Robson  and  Moynihan's  Diseases  qf  the  Pancreas. 

Diseases  of  the  Pancreas.  By  A.  W.  Mayo  Robson,  F.  R.  C.  S., 
Leeds,  Senior  Surgeon  to  Leeds  General  Infirmary ;  Emeritus  Pro- 
fessor of  Surgery,  Yorkshire  College;  and  B.  G.  A.  Movnihan,  M.  B., 
F.  R.  C.  S.,  Assistant  Surgeon  Leeds  General  Infirmary;  Demonstrator 
of  Anatomy,  Yorkshire  College.  Handsome  octavo  of  300  pages, 
illustrated.     Cloth,  $0.00  net. 

Salinger  and  Kalteyer's  Modern  Medicine. 

Modern  Medicine.  By  Julius  L.  Salinger,  M.  D.,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College ;  and  F.  J.  Kalteyer, 
M.  D.,  Assistant  Demonstrator  of  Clinical  Medicine,  Jefferson  Medical 
College.     Handsome  octavo,  801  pages,  illustrated.     Cloth,  ^4.00  net. 

Saundby's  Renal  and  Urinary  Diseases. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby,  M.  D. 
Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and  of  the 
Royal  Medico-Chirurgical  Society ;  Professor  of  Medicine  in  Mason 
College,  Birmingham,  etc.  Octavo,  434  pages,  with  numerous  illustra- 
tions and  4  colored  plates.     Cloth,  $2.50  net. 

Saunders'  Medical  Hand-Atlases. 

See  Pages  17,  18,  and  19, 

Saunders'  Pocket  Medical  Formulary,  sixth  Edition.  Revised. 

By  William  M.  Powell,  M.  D.,  author  of  "Essentials  of  Diseases  of 
Children":  Member  of  Philadelphia  Pathological  Society.  Contain- 
ing 1844  formulae  from  the  best-known  authorities.  With  an  Appendix 
containing  Posological  Table,  Formula  and  Doses  for  Hypodermic 
Medication,  Poisons  and  their  Antidotes,  Diameters  of  the  Female  Pelvis 
and  Fetal  Head,  Obstetrical  Table,  Diet  Lists,  Materials  and  Drugs 
used  in  Antiseptic  Surgery.  Treatment  of  Asphyxia  from  Drowning,  Sur- 
gical Remembrancer,  Tables  of  Incompatibles,  Eruptive  Fevers,  etc.,  etc. 
In  flexible  morocco,  with  side  index,  wallet,  and  flap.     $2.00  net. 


OF  W.  B.  SAUNDERS  a^  CO.  13 


Saunders'  Question-Compends.    see  Page  16. 

Scudder's   Fractures.      Third  Edition.  Revised. 

The  Treatment  of  Fractures.  By  Chas.  L.  Scudder,  M.  D.,  Assistant 
in  Clinical  and  Operative  Surgery,  Harvard  University  Medical  School. 
Octavo,  460  pages,  with  nearly  600  original  illustrations.  Polished 
Buckram,  tmmm  net ;   Half  Morocco,  |^HMBnet. 


Senn's  Genito- Urinary  Tuberculosis. 

Tuberculosis  of  the  Genito-Urinary  Organs,  Male  and  Female.      By 

Nicholas  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Surgery,  Rush 
Medical  College,  Chicago.  Handsome  octavo  volume  of  320  pages, 
illustrated.     Cloth,  $3.00  net. 

Senn's  Practical  Surgery. 

Practical  Surgery.  By  Nicholas  Senn,  M.  D.,  Ph.D.,  LL.  D.,  Pro- 
fessor of  Surgery,  Rush  Medical  College,  Chicago.  Octavo,  1133 
pages,  642  illustrations.  Cloth,  ^6.00  net;  Sheep  or  Half  Morocco, 
$7.00  net.     By  Subscription. 

Senn's  Syllabus  qf  Surgery. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged  in  con- 
formity with  "An  American  Text-Book  of  Surgery."  By  Nicholas 
Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Surgery,  Rush  Medical  Col- 
lege, Chicago.     Cloth,  $1.50  net. 

Senn's    Tumors.       second  Edition,  Revised. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  Nicholas  Senn,  M.  D., 
Ph.  D.,  LL.  D.,  Professor  of  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  718  pages,  with  478  illustrations,  including 
12  full-page  plates  in  colors.  Cloth,  ^5.00  net ;  Sheep  or  Half  Morocco, 
$6.00  net. 

SoUmann's  Pharmacology. 

A  Text-Book  of  Pharmacology  :  including  Therapeutics,  Materia  Medica, 
Pharmacy,  Prescription-Writing,  Toxicology,  etc.  By  Torald  Soll- 
MANN,  M.  D.,  Assistant  Professor  of  Pharmacology  and  Materia  Medica, 
Western  Reserve  University,  Cleveland,  Ohio.  Handsome  octavo, 
894  pages,  fully  illustrated.     Cloth,  $3.75  net. 

Starr's  Diets  for  Infants  an?  Children. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.  By  Louis 
Starr,  M.  D.,  Editor  of  "An  American  Text-Book  of  the  Diseases  of 
Children."  230  blanks  (pocket-book  size),  perforated  and  neatly  bound 
in  flexible  morocco.     $1.25  net. 

Stelwagon's  Diseases  qf  the  Skin. 

Diseases  of  the  Skin.  By  Henry  W.  Stelwagon,  M.  D.,  Clinical  Pro- 
fessor of  Dermatology,  Jefferson  Medical  College,  Philadelphia.  Royal 
octavo,  over  1000  pages,  with  over  200  text-cuts  and  26  colored 'plates. 
Cloth,  $6.00  net;  Sheep  or  Half  Morocco,  ;?7.oo  net. 


14  MEDICAL  PUBLICATIONS 


Stengel's    PatholO^.       Third  Edition.  Thoroughly  Revised. 

A  Text-Book  of  Pathology.  By  Alfred  Stengel,  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsylvania ;  Visiting  Physician  to 
the  Pennsylvania  Hospital.  Handsome  octavo,  873  pages,  nearly  400 
illustrations,  many  of  them  in  colors.  Cloth,  $5.00  net ;  Sheep  or  Half 
Morocco,  §6.00  net. 

Sten£(el  and  White  on  the  Blood. 

The  Blood  in  its  Clinical  and  Pathological  Relations.  By  Alfred 
Stengel,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Penn- 
sylvania ;  and  C.  Y.  White,  Jr.,  M.  D.,  Instructor  in  Clinical  Medicine, 
University  of  Pennsylvania.     In  Press. 

StPVen^'   Th«>ran*»iH'ir«  '^^^^  Edition,  Entirely 

OievenS      1  nerapeUXlCS.       Rewritten  and  Greatly  Enlarged. 

A  Text-Book  of  Modern  Therapeutics.  By  A.  A.  Stevens,  A.  M.,  M.  D., 
Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsylvania. 
Handsome  octavo  volume  of  about  550  pages.     Cloth,  jo.oo  net. 

Stevens'  Practice  qf  Medicine.    Fifth  Edition.  Revised. 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.  M., 
M.  D.,  Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsyl- 
vania. Specially  intended  for  students  preparing  for  graduation  and 
hospital  examinations.  Post-octavo,  519  pages;  illustrated.  Flexible 
Leather,  $2.00  net. 

Stewart's    PhysiolO^.       Fourth  Edition.  Revised. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For  Students  and 
Practitioners.  By  G.  N.  Stewart,  AL  A.,  M.  D.,  D.  Sc.,  Professor  of 
Physiology  and  Histolog}%  Western  Resene  University,  Cleveland, 
Ohio.  Octavo,  894  pages ;  336  illustrations  and  5  colored  plates. 
Cloth,  $3.75  net. 

Stoney's  Materia  Medica  for  Nurses. 

Materia  Medica  for  Nurses.  By  the  late  Emilv  A.  M.  Stonev,  Superin- 
tendent of  the  Training-School  for  Nurses,  Carney  Hospital,  South  Bos- 
ton, Mass.     Handsome  octavo  volume  of  306  pages.      Cloth,  Si -5°  net. 

Stoney's    Nursing.       second  Edition,  Revised. 

Practical  Points  in  Nursing.  For  Nurses  in  Private  Practice.  By  the 
late  Emily  A.  M.  Stonev,  Superintendent  of  the  Training- School  for 
Nurses,  Carney  Hospital,  South  . Boston,  Mass.  456  pages,  with  73 
engravings,  and  8  colored  and  half-tone  plates.     Cloth,  $1.75  net. 

Stoney's  Surgical  Technic  for  Nurses. 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  the  late  Emily  A.  M. 
Stonev,  Superintendent  of  the  Training  School  for  Nurses,  Carney  Hosp., 
South  Boston,  Mass.     i2mo  volume,  fully  illustrated.    Cloth,  $1.25  net. 

Thomas's   Diet   Lists.      Second  Edition.  Revised. 

Diet  Lists  and  Sick-Room  Dietary.  By  Jerome  B.  Thomas,  M.  D., 
Visiting  Physician  to  the  Home  for  Friendlecs  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to  the  Kings 
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OF  W.  B.  SAUNDERS  ^^  CO.  15 

Thornton's  Dose-Book  and  Prescription-Writing. 

Second  Edition,  Revised  and  Enlio-ged. 

•  Dose-Book  and  Manual  of  Prescription-Writing,  By  E.  Q.  Thornton, 
M.  D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila. 
Post-octavo,  362  pages,  illustrated.     Flexible  Leather,  $2.00  net. 

Vecki'S    Sexual    Impotence.        Third  Edition,  Revised  and  Enlarged. 

The  Pathology  and  Treatment  of  Sexual  Impotence.  By  Victor  G. 
Vecki,  M.  D.  From  the  second  German  edition,  revised  and  enlarged. 
Demi-octavo,  329  pages.     Cloth,  ^2.00  net. 

Vierordt*s  Medical  Diagnosis.    Fourth  Edition,  Revised. 

Medical  Diagnosis.  By  Dr.  Osv^ald  Vierordt,  Professor  of  Medicine, 
University  of  Heidelberg.  Translated,  with  additions,  from  the  fifth 
enlarged  German  edition,  with  the  author's  permission,  by  Francis  H. 
Stuart,  A.M.,  M.  D.  Handsome  octavo  volume,  603  pages;  194 
wood-cuts,  many  of  them  in  colors.  Cloth,  ;^4.oo  net;  Sheep  or  Half 
Morocco,  $5.00  net. 

Watson's  Handbook  for  Nurses. 

A  Handbook  for  Nurses.  By  J.  K.  Watson,  M.  D.  Edin.  American 
Edition,  under  supervision  of  A.  A.  Stevens,  A.M.,  M.  D.,  Lecturer 
on  Physical  Diagnosis,  University  of  Pennsylvania.  i2mo,  413  pages, 
73  illustrations.     Cloth,  $1.50  net. 

Warren's  Surgical  Patholo|(y.    second  Edition. 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren, 
M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard 
Medical  School.  Handsome  octavo,  873  pages;  136  relief  and  litho- 
graphic illustrations,  33  in  colors.  With  an  Appendix  on  Scientific 
Aids  to  Surgical  Diagnosis,  and  a  series  of  articles  on  Regional  Bacte- 
riology.    Cloth,  I5.00  net;   Sheep  or  Half  Morocco,  ;^6.oo  net. 

Warwick  and  Tunstall's  First  Aid  to  the  Injured  and 
Sick. 

First  Aid  to  the  Injured  and  Sick.  By  F.  J.  Warwick,  B.  A.,  M.  B., 
Cantab.,  M.  R.  C.  S.,  Surgeon-Captain,  Volunteer  Medical  Staff  Corps, 
London  Companies;  and  A.  C.  Tunstall,  M.  D.,  F.  R.  C.  S.  Ed., 
Surgeon-Captain  commanding  East  London  Volunteer  Brigade  Bearer 
Company.     i6mo,  232  pages;  nearly  200  illustrations.    Cloth,  gi. 00  net. 

Wolfs  Examination  qf  Urine. 

A  Handbook  of  Physiologic  Chemistry  and  Urine  Examination.  By 
Chas.  G.  L.  Wolf,  M.  D.,  Instructor  in  Physiologic  Chemistry,  Cornell 
University  Medical  College.  i2mo,  204  pages,  illustrated.  Cloth,  $1.25 
net. 


SAUNDERS' 
QUESTION-COMPENP  SERIES. 

Price,  Cloth,  81.00  net  per  copy,  except  when  otherwise  noted. 


'  Where  the  work  of  preparing  students'  manuals  is  to  end  we  cannot  say,  but  the  Saunders  Series, 
in  our  opinion,  bears  off  the  palm  at  present." — New  York  Medical  Record. 


1.  Essentials  of  Physiology.     By  Sidney  Budgett,  M.  D.     A  New  Work. 

2.  Essentials  of  Surgery.     By  Edward  Martin,  M.  D.     Seventh  edition,  revised,  with 

an  Appendix  and  a  chapter  on  Appendicitis. 

3.  Essentials  of  Anatomy.     By  Charles   B.   Nancrede,   M.  D.     Sixth  edition,  thor- 

oughly revised  and  enlarged. 

4.  Essentials  of  Medical  Chemistry,  Organic  and  Inorganic.     By  Lawrencs  Wolff, 

M.  D.     Fifth  edition,  revised. 

5.  Essentials  of  Obstetrics.     By  W.  Easterly  Ashton,  M.  D.     Fifth   edition,  revised 

and  enlarged. 

6.  Essentials  of  Pathology  and  Morbid  Anatomy.     By  F.  J.  Kalteyer,  M.  D.     In 

preparation. 

7.  Essentials  of  Materia  Medica,  Therapetitics,  and  Prescription-Writing.   B7  Henry 

Morris,  M.  D.     Fifth  edition,  revised. 

8.  9.    Essentials  of  Practice  of  Medicine.     By  Henry  Morris,  M.  D.     An  Appendix 

on  Urine  Examination.  By  Lawrence  Wolff,  M.  D.  Third  edition,  enl&rged 
by  some  300  Essential  Formulae,  selected  from  eminent  authorities,  by  Wm.  M. 
Powell,  M.  D.     (Double  number,  $1.50  net.) 

10.  Essentials  of  Gynecology.     By  Edwin  B.  Cragin,  M.  D.     Fifth  edition,  revised. 

11.  Essentials  of  Dbeases  of  the  Skin.     By  Henry  W.  Stelwagon,  M.  D.     Fourth 

edition,  revised  and  enlarged. 

12.  Essentials  of  Minor  Surgery,  Bandaging,  eoid  Venereal    Diseases.     By  Edward 

Martin,  M.  D.     Second  edition,  revised  and  enlarged. 

13.  Essentials    of   Legal    Medicine,   Toxicology,   and    Hygiene.     This  volume   is   at 

present  out  of  print. 

14.  Essentials  of  Diseases  of  the  Eye.     By  Edward  Jackson,  M.  D.     Third  edition, 

revised  and  enlarged. 

15.  Essentizds  of  Dbeases  of  Children.    By  William  M.  Powell,  M.  D.    Third  edition. 

16.  Essentials   of   Exetmination   of   Urine.     By   Lawrence   Wolff,  M.  D.      Colored 

"  Vogel  Scale."     (75  cents  net.) 

17.  Essentials  of  Diagnosis.     By  S.   Solis-Cohen,  M.  D.,  and  A.  A.  Eshner,  M.  D. 

Second  edition,  thoroughly  revised. 

18.  Essentials    of    Practice    of    Pharmacy.     By  Lucius   E.    Sayre.     Second   edition, 

revised  and  enlarged. 

19.  Essentials  of  Disezises  of  the  Nose  and  Throat.     By  E.  B.  Gleason,  M.  D.     Third 

edition,  revised  and  enlarged. 

20.  Essentitds  of  Bacteriology.     By  M.  V.  Ball,  M.  D.     Fourth  edition,  revised. 

21.  Essentials  of  Nervous  Disee^ses  and  Insanity.     By  John  C.  Shaw,  M.  D.     Third 

edition,  revised. 

22.  Essentials  of   Medical   Physics.     By  Fred  J.  Brockway,  M.  D.     Second  edition, 

revised. 

23.  Essentials  of  Medical  Electricity.     By  David  D.  Stewart,  M.  D.,  and  Edward 

S.  Lawrance,  M.  D. 

24.  Essentials  of   Diseases  of   the  Ear.     By  E.   B.   Gleason,  M.  D.     Third   edition, 

revised  and  greatly  enlarged. 

25.  Essentials  of  Histology.     By  Louis  Leroy,  M.  D.     Second  edition,  revised.     With 

85  original  illustrations. 

Pamphlet  containing  specimen  pages,  etc.,  sent  free  upon  application. 

16 


Saunders'  Medical    Hand-Atlases. 

VOLUMES   NOW   READY. 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical 
Diagnosis. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A.  Eshner, 
M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With 
182  colored  figures  on  68  plates,  64  text-illustrations,  259  pages  of  text. 
Cloth,  ^3.00  net. 

Atlas  of  Legal  Medicine. 

By  Dr.  E.  R.  von  Hofmann,  of  Vienna.  Edited  by  Frederick 
Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Department,  College  of 
Physicians  and  Surgeons,  New  York.  With  120  colored  figures  on  56 
plates  and  193  beautiful  half-tone  illustrations.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Diseases  of  the  Larynx. 

By  Dr.  L.  Grunwald,  of  Munich.  Edited  by  Charles  P.  Grayson, 
M.  D.,  Physician-in-Charge,  Throat  and  Nose  Department,  Hospital  of 
the  University  of  Pennsylvania.  With  107  colored  figures  on  44  plates, 
25  text-illustrations,  and  103  pages  of  text.     Cloth,  ^2.50  net. 

Atlas  and  Epitome  of  Operative  Surgery. 

Second  Edition,  Thoroughly  Revised  eoid  Greatly  Enlarged. 

By  Dr.  O.  Zuckerkandl,  of  Vienna.  Edited  by  J.  Chalmers 
DaCosta,  M.  D.,  Professor  of  Principles  of  Surgery  and  of  Clinical  Sur- 
gery, Jefferson  Medical  College,  Phila.  With  40  colored  plates,  278 
text-illustrations,  and  410  pages  of  text.     Cloth,  ^3.50  net. 

Atlas  and   Epitome   of   Syphilis   and  the  Venereal 
Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolton 
Bangs,  M.  D.,  Professor  of  Genito-Urinary  Surgery,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  With  71  colored 
plates,  16  illustrations,  and  122  pages  of  text.     Cloth,  $$.$0  net. 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye. 

By  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E.  de  Schweinitz,  M.  D., 
Professor  of  Ophthalmology,  Jefferson  Medical  College,  Phila.  With  76 
colored  figures  on  40  plates;  228  pages  of  text.     Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Skin  Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  Henry  W.  Stel- 
wagon,  M.  D.,  Clinical  Professor  of  Dermatology,  Jefferson  Medical 
College,  Philadelphia.  With  63  colored  plates,  39  half-tone  illustra- 
tions, and  200  pages  of  text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Special  Pathological  Histology. 

By  Dr.  H.  DDrck,  of  Munich.  Edited  by  Ludvig  Hektoen,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  Two  Parts. 
Part  I.,  including  Circulatory,  Respiratory,  and  Gastro-intestinal  Tracts, 
120  colored  figures  on  62  plates,  158  pages  of  text.  Part  11.,  including 
Liver,  Urinary  Organs,  Sexual  Organs,  Nervous  System,  Skin,  Muscles, 
and  Bones,  123  colored  figures  on  60  plates,  and  192  pages  of  text. 
Per  part:  Cloth,  $3.00  net. 

17 


Saunders'  Medical  Hand-Atlases. 


VOLUMES  JUST  ISSUED. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents. 

By  Dr.  Ed.  Golebiewski,  of  Berlin.  Translated  and  edited,  with 
additions,  by  Pearce  Bailey,  M.  D.,  Attending  Physician  to  the  Depart- 
ment of  Corrections  and  to  the  Almshouse  and  Incurable  Hospitals, 
New  York.  With  40  colored  plates,  143  text-illustrations,  and  S49 
pages  of  text.     Cloth,  $4.00  net. 

Atlas  and  Epitome  of  Gynecolo^. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  Ger- 
man Edition.  Edited,  with  additions,  by  Richard  C.  Norris,  A.  M., 
M.  D.,  Gynecologist  to  the  Methodist  Episcopal  and  the  Philadelphia 
Hospitals  ;  Surgeon-in-Charge  of  Preston  Retreat,  Philadelphia.  ^Vith 
90  colored  plates,  65  text-illustrations,  and  308  pages  of  text.  Cloth, 
$3.50  net. 

Atlas  and  Epitome  of  the  Nervous  System  and  its 
Diseases. 

By  Prof.  Dr.  Chr.  Jakob,  of  Erlangen.  From  the  Second  Revised  and 
Enlarged  German  Edition.  Edited,  with  additions,  by  Edward  D. 
Fisher,  M.  D.,  Professor  of  Diseases  of  the  Nervous  System,  University 
and  Bellevue  Hospital  Medical  College,  N.  Y.  With  83  plates ;  copious 
text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Fifth  Revised  and 
Enlarged  Gertnan  Edition.  Edited,  with  additions,  by  J.  Clifton 
Edgar,  M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell 
University  Medical  School.  With  126  colored  illustrations.  Cloth, 
|i2.oo  net. 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and  Treat- 
ment. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  and 
Enlarged  German  Edition.  Edited,  with  additions,  by  J.  Clifton 
Edgar,  M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell 
University  Medical  School.  72  colored  plates,  text-illustrations,  and 
copious  text.     Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthal- 
moscopic Dia^^nosis. 

By  Dr.  O.  Haab,  of  Zurich.  From  the  Third  Revised  and  Enlarged 
German  Edition.  Edited,  with  additions,  by  G.  E.  de  Schweinitz, 
M.  D.,  Professor  of  Ophthalmology,  Jefferson  Medical  College,  Phila- 
delphia. With  152  colored  figures  and  82  pages  of  text.  Cloth,  $3.00 
net. 

ADDITIONAL  VOLUMES  IN  PREPARATION. 
18 


Saunders'  Medical  Hand-Atlases. 

VOLUMES   JUST   ISSUED. 

Atlas  and  Epitome  of  Bacteriolo^. 

Including  a  Hand-Book  of  Special  Bacteriologic  Diagnosis.  By  Prof. 
Dr.  K.  B.  Lehmann  and  Dr.  R.  O.  Neumann,  of  WUrzburg.  From 
the  Second  Enlarged  and  Revised  German  Edition.  Edited,  with  addi- 
tions, by  G.  H.  Weaver,  M.  D.,  Assistant  Professor  of  Pathology  and 
Bacteriology,  Rush  Medical  College,  Chicago.  In  Two  Parts.  Part  I., 
consisting  of  632  colored  illustrations  on  69  lithographic  plates.  Part  II., 
consisting  of  511  pages  of  text,  illustrated.     Per  part:  Cloth,  $2.50  net. 

Atlas  and  Epitome  of  Otology. 

By  Dr.  Gustav  Bruhl,  of  Berlin,  with  the  collaboration  of  Prof.  Dr. 
A.  Politzer,  of  Vienna.  Edited,  with  additions,  by  S.  "MacCuen 
Smith,  M.  D.,  Clinical  Professor  of  Otology,  Jefferson  Medical  College, 
Philadelphia.  244  colored  figures  on  39  plates,  99  text-cuts,  and  292 
pages  of  text.     Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Abdominal  Hernias. 

By  Privatdocent  Dr.  Georg  Sultan,  of  Gottingen.  Edited,  with 
additions,  by  William  B.  Coley,  Clinical  Lecturer  on  Surgery,  Colum- 
bia University  (College  of  Physicians  and  Surgeons),  New  York ;  Sur- 
geon to  the  General  Memorial  Hospital,  New  York.  With  43  colored 
figures,  on  36  plates,  100  text-cuts,  and  250  pages  of  text.     In  Press. 

Atlas  and  Epitome  of  Fractures  and  Luxations. 

By  Prof.  Dr.  H.  Helferich,  of  Greifswald.  Edited,  with  additions,  by 
Joseph  C.  Bloodgood,  Associate  in  Surgery,  Johns  Hopkins  University, 
Baltimore.  With  215  colored  figures  on  72  plates,  144  text-cuts,  42 
skiagraphs,  and  over  300  pages  of  text.     In  Press. 

Atlas  and  Epitome  of  Diseases  of  Mouth,  Throat,  and 
Nose. 

By  Dr.  L.  Grunwald,  of  Munich.  Erotn  the  Second  Revised  and 
Enlarged  German  Edition.  Edited,  with  additions,  by  James  E.  New- 
comb,  M.  D.,  Clinical  Instructor  in  Laryngology,  Cornell  University 
Medical  School.  With  42  colored  figures,  39  text-cuts,  and  225  pages 
of  text.     In  Press. 

Atlas  and  Epitome  of  Normal  Histolo^. 

By  Privatdocent  Dr.  J.  Sobotta,  of  Wiirzburg.  Edited,  with  addi- 
tions, by  G.  Carl  Huber,  M.  D.,  Junior  Professor  of  Anatomy  and 
Director  of  the  Histological  Laboratory,  University  of  Michigan.  With 
80  colored  figures  and  68  text-cuts  from  the  original  of  W.  Freytag,  and 
275  pages  of  text. 

Atlas  and  Epitome  of  Operative  Gynecolo^. 

By  Dr.  Oskar  Schaeffer,  Privatdocent  at  the  University  of  Heidel- 
berg. With  42  colored  figures  and  21  text-cuts  from  the  original  of  A. 
Schmitson,  and  1 25  pages  of  text. 

ADDITIONAL  VOLUMES  IN  PREPARATION. 
19 


NOTHNAGEL'S   ENCYCLOPEDIA 

OF 

PRACTICAL  MEDICINE 

AMERICAN   EDITION 

Edited   by  ALFRED  STENGEL.  M.  D. 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania ;  Vbiting 
Physician  to  the  Pennsylvania  Hospital 

IT  is  universally  acknowledged  that  the  Germans  lead  the  world   in  Internal 
Medicine  ;  and  of  all  the  German  works  on  this  subject,  Nothnagel's  "  Speci- 

elle  Pathologie  und  Therapie  "  is  conceded  by  scholars  to  be  without  question 
the  best  System  of  Medicine  in  existence.  So  necessarj'  is  this  book  in  the  study 
of  Internal  Medicine  that  it  comes  largely  to  this  country-  in  the  original  German. 
In  view  of  these  facts,  Messrs.  W.  B.  Saunders  &  Company  have  arranged  with 
the  publishers  to  issue  at  once  an  authorized  Americaoi  edition  of  this  great  ency- 
clopedia of  medicine. 

For  the  present  a  set  of  ten  volumes,  representing  the  most  practical  part 
of  this  excellent  encyclopedia,  and  selected  with  especial  thought  of  the  needs 
of  the  practical  physician,  will  be  published.  These  volumes  will  contain  the 
real  essence  of  the  entire  work,  and  the  purchaser  will  therefore  obtain  at  less 
than  half  the  cost  the  cream  of  the  original.  Later  the  special  and  more  strictly 
scientific  volumes  will  be  oflFered  from  time  to  time. 

The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both 
English  and  German,  and  each  volume  will  be  edited  by  a  prominent  specialist 
on  the  subject  to  which  it  is  devoted.  It  will  thus  be  brought  thoroughly  up  to 
date,  and  the  American  edition  will  be  more  than  a  mere  translation  of  the  Ger- 
man ;  for,  in  addition  to  the  matter  contained  in  tlie  original,  it  will  represent  the 
very  latest  views  of  the  leading  American  and  English  specialists  in  the  various 
departments  of  Internal  Medicine.  The  whole  System  will  be  under  the  edi- 
torial supervision  of  Dr.  Alfred  Stengel,  who  will  select  the  subjects  for  the 
American  edition,  and  arrange  for  the  editing  of  the  different  volumes. 

Unlike  most  encyclopedias,  the  publication  of  this  work  will  not  be  extended 
over  a  number  of  years,  but  five  or  six  volumes  will  be  issued  during  the  coming 
year,  and  the  remainder  of  the  series  at  the  same  rate.  Moreover,  each  volume 
will  be  revised  to  the  date  zi  its  publication  by  the  eminent  editor.  This  will 
obviate  the  objection  that  has  heretofore  existed  to  systems  published  in  a  number 
of  volumes,  since  the  subscriber  will  receive  the  completed  work  while  the  earlier 
volumes  are  still  fresh. 

The  usual  method  of  publishers,  when  issuing  a  work  of  this  kind,  has  been 
to  compel  physicians  to  take  the  entire  System.  This  seems  to  us  in  many  cases 
to  be  undesirable.  Therefore,  in  purchasing  this  encyclopedia,  physicians  will  be 
given  the  opportunity  of  subscribing  for  the  entire  System  at  one  time  ;  but  any 
single  volume  or  any  number  of  volumes  may  be  obtained  by  those  who  do  not 
desire  the  complete  series.  This  latter  method,  while  not  so  profitable  to  the  pub- 
lisher, offers  to  the  purchaser  many  adveoitages  which  will  be  appreciated  by  those 
who  do  not  care  to  sub-^cribe  for  the  entire  work  at  one  time. 

This  American  edition  of  Nothnagel's  Encyclopedia  will,  without  question, 
form  the  greatest  System  of  Medicine  ever  produced,  and  the  publishers  are  con- 
fident that  it  will  meet  with  general  favor  in  the  medical  profession. 

20 


NOTHNAGEL*S 
ENCYCLOPEDIA   OF  PRACTICAL  MEDICINE. 

AMERICAN   EDITION. 

VOLUMES  JUST  ISSUED  AND  IN  PRESS. 

TYPHOID  AND  TYPHUS  FEVERS.     By  Dr.  H.  Curschmann,  of  Leipsic. 

Editor,  William  Osier,  M.D.,  F.R.C.P.,  Professor  of  the  Principles  and  Practice  of 
Medicine  in  Joiins  Ho|3kins  University,  Baltimore.  Handsome  octavo,  646  pages, 
72  valuable  text  illustrations,  and  two  lithographic  plates.  Cloth,  $5.00  net;  Half 
Morocco,  $6.00  net.     Just  Ready. 

VARIOLA  (including  VACCINATION).  By  Dr.  H.  Immermann,  of  Basle.  VARI- 
CELLA.  By  Dk.  Th.  von  JiIrgensen,  of  TUbingen.  CHOLERA  ASIATICA 
and  CHOLERA  NOSTRAS.  By  Dr.  C.  Liebermeistkr,  of  'liibingen.  ERY- 
SIPELAS  and  ERYSIPELOID.  By  Dr.  H.  Lenhartz,  of  Hamburg.  PER- 
TUSSIS  and  HAY-FEVER.  By  Dr.  G.  Sticker,  of  Giessen. 
Editor,  Sir  J.  W.  Moore,  B.A.,  M.D.,  F.R.C.P.I.,  Professor  of  the  Practice  of  Medi- 
cine, Royal  College  of  Surgeons,  Ireland.  Handsome  octavo  of  682  pages,  illustrated. 
Cloth,  I5. 00  net;   Half  Morocco,  $6.00  net.     Just  Ready. 

DIPHTHERIA.     An  original   article  by  William    P.  Northrup,  M.D.,  of  New  York. 
Measles,  Scairlet  Fever,  Rotheln.      By  Dr.  Th.  von  Jurgensen,  of  Tiilnngen. 
Editor,  Willison  P.  Northrup,  M.  D.,  Professor  of  Pediatrics,  Univeisity  and  Bellevue 
Medical  College,  N.  Y.      Handsome  octavo,  672  pages,  illustrated,  including  24  full- 
page  plates,  3  in   colors.      Cloth,  ^5.co  net ;   Half  Morocco,  ^6.00  net.     Just  Ready. 

DISEASES  OF  THE  BRONCHI.  Bv  Dr.  F.  A.  Hoffmann,  of  Leipsic.  DIS- 
EASES OF  THE  PLEURA.  By  Dr.  O.  Rosenbaum,  of  Berlin.  PNEUMONIA. 
By  Dr.  E.  Aufrecht,  of  Magdeburg. 

Editor,  John  H.  Musser,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsyl- 
vania. Handsome  octavo,  700  pages,  7  full-page  lithographs  in  colors.  Cloth,  ;^S.OO 
net ;  Half  Morocco,  $6.00  net.    just  Ready. 

DISEASES  OF  THE  LIVER.  By  Drs.  H.  Quincke  and  G.  Hoppe-Seyler,  of  Kiel. 
DISEASES  OF  THE  PANCREAS.     By  Dr.  L.  Oser,  of  Vienna.     DISEASES 

OF  THE  SUPRARENALS.     By  Dr.  E.  NEUssER,of  Vienna. 

Editors,  Frederick  A.  Packard,  M.D.,  Physician  to  the  Penna.  and  the  Children's 
Hospitals,  Phila.  ;  and  Reginald  H.  Fitz,  A.  M.,  M.  D..  Hersey  Prof,  of  the  Theory 
and  Practice  of  Physic,  Harvard  Univ.  Handsome  octavo  of  750  pages,  illustrated. 
Cloth,  $5.00  net ;   Half  Morocco,  ^6.00  net.     Just  Ready. 

INFLUENZA  AND  DENGUE.  By  Dr.  O.  Leichtenstern,  of  Cologne.  MALA. 
RIAL  DISEASES.     By  Dr.  J.   Mannaberg,  of  Vienna. 

Editor,  Ronald  Ross,  F.R.C.S.,  Eng.,  D.P.H.,  F.R.S.,  Major,  Indian  Medical 
Service,  retired ;  Walter  Myer-;,  Lecturer,  Liverpool  School  of  Trc^sical  Medicine, 
Liverpool.      Handsome  octavo,  700   pages,  7  full-page  lithographs  in  colors. 

ANEMIA,  LEUKEMIA,  PSEUDOLEUKEMIA,  HEMOGLOBINEMIA.     By  Dr.  P. 

Ehrlich,  of  Frankfort-on-the-Main,  Dr.  A.  Lazarus,  of  Charkttenburg,  and  Dr. 
Felix  Pinkus,  of  Berlin.  CHLOROSIS.  By  Dr.  K.  von  Noorden,  of  Frank- 
fort-on-the-Main. 

Editor,  Alfred  Stengel.  M.D.,  Professor  of  Clinical  Medicine,  University  of  Pennsyl- 
vania.    Handsome  octavo,  750  pages,  5  full-page  lithographs  in  colors. 

TUBERCULOSIS  AND  ACUTE    GENERAL    MILIARY   TUBERCULOSIS.     By 

Dr.  G.  Cornet,  of  Berlin. 

Editor  to  be  announced  later.      Handsome  octavo,  700  pages. 

DISEASES  OF  THE  STOMACH.     By  Dr.  F.  Riegel,  of  Giessen. 

Editor,  Cheurles  G.  Stockton,  M.D.,  Professor  of  Medicine,  University  of  Buffalo. 
Handsome  octavo,  800  pnges,  with  29  text- cuts  and  6  full-page  plates. 

DISEASES  OF  THE   INTESTINES  AND   PERITONEUM.     By  Dr.  Hermann 

NoTHNAGEL,  of  Vienna. 

Editor,  Humphry  D.  Rolleston,  M.D.,  F.R.C.P.,  Physician  to  and  Lecturer  on  Pathol- 
ogy at  .St.  George's  Hospital,  London.    Handsome  octavo,  800  pages,  finely  illustrated. 

21 


CLASSIFIED   LIST 

OF  THE 

MEDICAL    PUBLICATIONS 


OF 


W.  B.  SAUNDERS  Cf  COMPANY 


ANATOMY,  EMBRYOLOGY, 
HISTOLOGY. 
Bohm,  Davidoff,  andHuber — Histology,  .     4 
Clarkson — A  Text-Book  ot  Histology,  .    .     5 
Haynes— A  Manual  of  Anatomy,  ....      8 
Heisler — A  Text-Book  of  Embryology,  .    .     8 

Leroy — Essentials  of  Histology, 16 

McClellan — Art  Anatomy 10 

McClellan — Regional  Anatomy, ib 

Nancrede — Essentials  of  Anatomy, ....   16 
Nancrede — Essentials   of     Anatomy    and 

Manual  of  Practical  Dissection 11 

Sobotta — Atlas  of  Normal  Histology,    .    .    19 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology 16 

Eyre — liacteriologic  Technique 7 

Frothingham — Laboratory  Guide 7 

Qorham — Laboratory  Bacteriology,  ...  7 
LehTnann  and  Neumann — Atlas  of  Bacte- 
riology   19 

Levy  and  Elemperer's  Clinical  Bacteri- 
ology   10 

Mallory  and  Wright— Pathological  Tech- 
nique   10 

McFarland — Pathogenic  Bacteria 11 

CHARTS,  DIET-LISTS,  ETC 

Griffith— Infant's  Weight  Chart, 8 

Keen — Operation  Blank 9 

Laine — Temperature  Chart, 10 

Meigs — Feeding  in  Early  Infancy 11 

Starr — Diets  for  Infants  and  Children,  .    .  13 

Thomas — Diet-Lists, 14 

CHEMISTRY  AND  PHYSICS. 

Brockway— Essentials  of  Medical  Physics,  16 

Jelliffe  and  Biekman — Chemistry,    ...  9 

Wolf — Urine  Examination, m 

Wolff — Essentials  of  Medical  Chemistry,  .  16 

CHILDREN. 

American  Text-Book  Dis.  of  Children,  .   .     i, 

Orlfflth — Care  of  the  Babv 8  i 

Griffith— Infant's  Weight  Chart 8  i 

Meigs — Feeding  in  Early  Infancy 11 

Powell —  Essentials  of  Diseases  of  Children,  16 

Starr — Diets  for  Infants  and  Children,  .    .  13 

DIAGNOSIS. 
Cohen  and  Eshner — Essentials  of  Diag- 
nosis        16 

Corwln — Physical  Diagnosis 5 

Vlerordt — Medical  Diagnosis 15 

DICTIONARIES. 

The  American  Illustrated  Medical  Dic- 
tionary      3 

The  American  Pocket  Medical  Dictionary,      3 
Morten — Nurses'  Dictionary 11 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text-Book  of  Diseases  of 

the  Eve,  Ear.  Nose,  and  Throat I 

Bruhl  and  Politzer— Atlas  of  Otology,      .  19 
■neSchweinitz  — Diseases  of  the  Eye,    .    .  6 
Friedrich  and  Curtis — Rhinology,  Laryn- 
gology and  Otology 7 

Gleason — Essentials  of  Diseases  of  the  Ear,  16 

Gleason — Ess.  of  Dis.  of  Nose  and  Throat,  16 

Gradle — Ekr,  Nose,  and  Throat 7 

Grant — Surgery  of  Face,  Mouth,  and  Jaws,  8 
Griinwald — Atlas  of  Mouth,  Throat,  and 

Nii-se 19 

Griinwald — Atlas     of    Diseases     of     the 

Larynx 17 

Haab — Atlas  of  External  Diseases  of  the 

Eye, 17 

Haab — Atlas  of  Ophthalmoscopy 18 

Jackson — Manual  of  Diseases  of  the  Eye,  9 

Jackson — Essentials  of   Diseases  of  Eye,  16 

Kyle— Diseases  of  the  Nose  and  Throat,  .  9 

GENlTaURINARY. 

An  American  Text-Book  of  Gemto-nri- 
nary  and  Skin  Diseases 2 

Hyde  and  Montgomery— Syphilis  and  the 
Venereal  Diseases 8 

Martin — Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases.     .    .    16 

Mracek — Atlas  of  Syphilis  and  the  Vene- 
real Diseases I7 

Saundby — Renal  and  Urinary  Diseases,  .  .    12 

Senn — Genito-Urinary  Tuberculosis,  ...    13 

Vecki — Sexual  Impotence, 15 

GYNECOLOGY. 

American  Text-Book  of  Gynecology, 
Cragin — Essentials  of  Gynecology,  .  . 
Garrigues — Diseases  of  Women,  .  . 
Long — Syllabus  of  Gynecology,  .  .  . 
Penrose — Diseasesof  Women, .  .  .' . 
Schaeffer — Atlas  of  Operative  Gynecology,  19 
Schaeffer — Atlas  of  Gynecology 18 

HYGIENE. 

Abbott — Hvgiene  of  Transmissible  Diseases    4 

Bergey — Principles  of  Hygiene 4 

Pyle — Personal  Hygiene 12 

MATERIA  MEDICA,  PHARMACOL- 
OGY, AND  THERAPEUTICS. 

American  Text-Book  of  Therapeutics 
Butler — Text-Book    of    Materia    Medica 

Therapeutics,  and  Pharmacology, 
Morris — Ess.  of  M.  M.  and  Therapeutics 
Saunders'  Pocket  Medical  Formulary,  . 

Sayre — Essentials  of  Pharmacy 

Sollmann — Text- Book  of  Pharmacology 
Stevens — Manual  of  Therapeutics,  .  . 
Stoney — Materia  Medica  for  Nurses,  . 
Thornton — Prescription-Writing,   .   .    . 


A 


MEDICAL  PUBLICATIONS  OF  IV.  B.  SAUNDERS  &>  CO.  23 


MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

Chapman — M  e  d  i  c  a  1  J  urisprudence  and 

Toxicology 5 

Crothers — MorphinisTn 6 

Goletoiewski— Atlas  of  Diseases  Caused  by 

Accidents 18 

Hofmann — Atlas  of  Legal  Medicine,  ...  17 

NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

Brower — Manual  of  Insanity 5 

Chapln — Compendium  of  Insanity,    ...  5 
Chlircll  and  Peterson — Nervous  and  Men- 
tal Diseases 5 

Jakob— Atlas  of  Nervous  System,  .        .    .  18 
Shaw — Essentials  of  Nervous  Diseases  and 

Insanity 16 

NURSING. 

Davis — Obstetric  and  Gynecologic  Nursing,    6 

Orifflth— I  he  Care  of  the  Baby 8 

Meigs — Feeding  in  Early  Infancy 11 

Morten — Nurses'  Dictionary 11 

Stoney — Materia  Medica  for  Nurses,      .    .  14 

Stoney — Practical  Points  in  Nursing,      .    .  14 

Stoney — Surgical  Technic  for  Nurses,    .    .  14 

Watson — Handbook  for  Nurses 15 

OBSTETRICS. 

An  American  Text-Book  of  Obstetrics,    .  2 

Ashton — Essentials  of  Obstetrics 16 

Boislini^re — Obstetric  Accidents,  ....  4 

Dorland — .Vlodern  Obstetrics 6 

Hirst— Text-Book  of  Obstetrics 8 

Norris — Syllabus  of  Obstetrics 11 

Schaeffer — Atlas  of  Labor  and  Operative 

Obstetrics .18 

Schaeffer — Atlas  of  Obstetrical  Diagnosis 

and  Treatment, 18 

PATHOLOGY. 
An  American  Text-Book  of  Pathology,    .  2 
Diirck — .Atlas  of  Pathologic  Histology,  .    .  17 
Kalteyer— Essentials  of  Pathology,    ...  16 
Mallory  and  Wright— Pathological  Tech- 
nique   10 

Senn — Pathology  and  Surgical  Treatment 

of  Tumors 13 

Stengel— Text-Book  of  Pathology,    .        .  14 

Stengel  and  White— Blood 14 

Warren— Surgical   Pathology  and  Thera- 
peutics   15 

PHYSIOLOGY. 

An  American  Text-Book  of  Physiology,  2 

Budgett  — Essentials  of  Physiology,    ...  16 

Raymond — Human  Physiology 12 

Stewart — Manual  of  Physiology,    ....  14 

PRACTICE  OF  MEDICINE. 

An  American  Year-Book  of  Med.  &  Surg.,  3 

An  American  Text-Book  of  Theo.  &  Prac,  3 

Anders — Practice  of  Medicine 4 

Eichhorst — Practice  of  Medicine 6 

Lockwood — Manual    of   the    Practice    of 

Medicine, 10 

Morris — Ess.  of  Practice  of  Medicine,  .    .  16 

Nothnagel's  Encyclopedia 20,  21 

Salinger  and  Kalteyer — Mod.  Medicine,  12 

Stevens — .Manual  of  Practice  of  Medicine,  14 


SKIN  AND  VENEREAL. 

An    American    Text-Book     of    Genito- 
urinary and  Skin  Diseases 2 

Hyde  and  Montgomery— Syphilis  and  the 

Venereal   Diseases 8 

Martin — Essentials    of     Minor     Surgery, 

Bandaging,  and  Venereal  Diseases,    .    .  16 

Mracek — .\tlas  of  Diseases  of  the  Skin,    .  17 

Stelwagon — Diseases  of  Skin 13 

Stelwagon—  Ess.  of  Diseases  of  the  Skin,  16 

SURGERY. 

An  American  Text-Book  of  Surgery,   .   .  2 
An  American  Year-Book  of  Medicine  and 

Surgery 3 

Beck — Fractures, 4 

Beck — Manual  of  Surgical  Asepsis,    ...  4 

DaCosta — Manual  of  Surgery 6 

Helferich — Atlas  of  Fractures 19 

International  Text-Book  of  Surgery,   .   .  9 

Keen — Operation  Blank 9 

Keen — The    Surgical   Complications    and 

Sequels  of  Typhoid  Fever 9 

Macdonald — Surgical  Diagnosis  and  Treat- 
ment   10 

Martin — Essentials    of    Minor    Surgery, 

Bantlaging,  and  Venereal  Diseases,    .    .  16 

Martin — Essentials  of  Surgery 16 

Moore — Orthopedic  Surgery 11 

Nancrede — Principles  of  Surgery 11 

Pye — Bandaging  and  Surgical  Dressing,    .  12 

Scudder — Treatment  of  Fractures,     ...  13 

Senn — Genito-Urinary  Tuberculosis,  ...  13 

Senn — Practical  Surgery, 13 

Senn — Syllabus  of  Surgery 13 

Senn — Tumors 13 

Sultan — Atlas  of  Abdominal  Hernia,     .    .  19 
Warren — Surgical  Pathology  and  Thera- 
peutics   15 

Zuckerkandl — Atlas  of  Operative  Surgery,  17 

URINE  AND  URINARY  DISEASES. 

Ogden — Clinical  lixamination  of  the  Urine,    11 
Saundhy — Renal  and  Urinary  Diseases,    .    12 

Wolf — Urine  Examination 15 

Wolff — ^Essentials  of  Examination  of  Urine,  16 

MISCELLANEOUS. 

Bastin — Laboratory  Exercises  in  Botany,  .     4 
Qalbraith— Four     Epochs    of    Woman's 

Life, 7 

Oolebiewski — Atlas   of    Diseases  Caused 

by  Accidents, 18 

Gould  and  Pyle — Anomalies  and  Curiosi- 
ties of  Medicine 7 

Grafstrom — Massage 8 

Keating — Examination  for  Life  Insurance,     9 
Robson  and  Moynihan— Diseases  of  the 

Pancreas 12 

Saunders'  Medical  Hand-Atlases,  .  17,  18,  19 
Saunders'  Pocket  Medical  Formulary,  .    .    12 

Saunders'  Question-Compends 16 

Stewart    and   Lawrance — Essentials  of 

Medical  Electricity 16 

Thornton — Dose-Book     and     Manual    of 

Prescription-Writing 15 

Warwick  and  TunstaJl— First  Aid  to  the 
j       Injured  and  Sick 15 


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